Encounter completion — orders & prescribing

Order medications, labs, imaging & more

The Orders section is one search box for everything you order at the visit — prescriptions, lab panels, imaging, referrals, screeners, and forms. Pick a destination pharmacy first so prescriptions know where to go.

1. Choose the pharmacy. Use Select pharmacy… to search the pharmacy directory; the list is sorted Closest to Physician. Add or edit pharmacies with Manage pharmacies.
2. Search and add. Type into Search orders and press Search & Add to open the Search Orders window. Filter by tab: All, Medication, Lab, Imaging, Referral, Screeners, Forms, or Favorites. Each result shows its name, brand names, and type; controlled medications are flagged with their schedule (for example Schedule: CIV).
3. Watch the renal cue. Latest Cr under the order list surfaces the most recent creatinine so you can dose-adjust without leaving the screen.

Write a structured prescription

Selecting a medication opens Edit Medication, where you build the sig from structured fields. Hero EMR assembles the directions and a one-click Auto-fill proposes a starting regimen with dosing guidance.

1. Build the sig. Set Action, Route, Dose (amount + unit), Frequency, Duration, Dispense (amount + unit), and Refills. The generated sig (for example “Take 0.5 tablet by mouth once daily for 30 days”) updates as you go.
2. Let Auto-fill propose a regimen. Auto-fill populates the structured fields and surfaces a Medication Hero dosing note — e.g. “For anxiety, clonazepam initial adult dose is 0.25–0.5 mg PO daily, may increase to 1 mg daily as needed.” Adjust anything before saving.
3. Set substitution and pharmacy notes. Toggle Substitution Allowed and add a Note to Pharmacy if needed, then Save Changes to drop the order onto the list.

Read the medication safety checks

Every medication order carries a row of five Medication Hero checks. They run automatically and show green when clear; click any icon for the detail. A red or amber result means review before you sign.

Link each order to a diagnosis

Orders should be tied to the diagnosis that justifies them. The Associations grid — diagnoses down the side, orders across the top — lets you check the box where they intersect. Linking supports medical necessity and is required before a prescription can be sent.

1. Open the Associations grid. It appears under the order list once you have at least one diagnosis and one order.
2. Check the intersections. Tick the box where a diagnosis row meets an order column (for example F41.1 × Clonazepam). The footer tracker shows Linked (0/1) in amber until every order is linked, then flips to a green Linked.

Sign controlled prescriptions (EPCS)

Non-controlled prescriptions send when you finalize the visit. Controlled substances (Schedule II–V) require EPCS — DEA-regulated two-factor signing — before they can be transmitted. The order’s Sign & Send button is labelled 2FA required and stays disabled until a pharmacy is selected and a diagnosis is linked.

1. Select a pharmacy and link the diagnosis. Both are prerequisites; the button’s tooltip tells you what’s still missing (“Cannot send: Select a pharmacy, Associate a diagnosis with this medication”).
2. Click Sign & Send. The Controlled Rx Mobile Approval dialog opens. It restates the full prescription — patient and DOB, medication with its schedule, directions, refills, and the prescriber’s name, address, and DEA number — alongside the legal signing attestation.
3. Check the PDMP. The dialog shows a PDMP not checked indicator with a Run PDMP button; run it to query the state database before signing where your state requires it.
4. Complete two-factor approval. Choose Start mobile approval to push the request to your registered phone, or Enroll passkey if you haven’t set up a second factor. Completing 2FA signs the prescription and authorizes transmission to the pharmacy.