3 Steps to Simplify EHR Software Charting for Medications

Explore three actionable steps for unchaining your practice from medication data entry burden within EHR software.

Entrepreneurial Physician

Key Takeaways

Reconciling medications, allergies, and pharmacy preferences takes away from top-of-license care.
The right EHR software that leverages automation—such as a flexible medication chart template—can streamline the process.
When it comes to collecting data, remember: patients can do some of the heavy lifting.

As a practice owner, chances are you’re well-acquainted with entering data into EHRs. However, that doesn’t mean this process is simple and carefree.

Enter managing medications and prescriptions. It’s an unavoidable part of every patient encounter that requires routine data entry. But does this process have to be time-consuming? By rethinking your approach to medication data entry and reconciliation, you can streamline your workflow and spend more time focusing on patient care.

Pairing the right focuses with appropriate EHR software, you can minimize the hassle, align your team around clear goals, and build a system that works for your practice.

Why Medication Charting Deserves Attention

If you’re like most psychiatrists, you probably spend a lot of time reconciling medications, allergies, and pharmacy preferences before you can even begin a patient encounter. While important, these tasks can be tedious and mentally draining—especially when the burden falls squarely on you or your staff’s shoulders.

The good news is, it doesn’t have to be this way. With the right systems in place—such as those that leverage a flexible medication chart template—you can delegate much of this work to technology, freeing you to focus on delivering care rather than data entry.

Imagine starting an appointment with a chart that’s nearly complete:

The patient’s medication list is accurate.
Allergies are up-to-date.
Their preferred pharmacy is on file.

No guesswork. No last-minute scrambling. Just a smooth start to the visit. That’s the goal we’re aiming for.

Step 1: Understand the Problem and Set Goals

Before setting a goal, understanding the problem to be solved and aligning your practice around solving it is the first step.

What’s usually the main sticking point? Put simply, having a complete and correct patient medication list shouldn’t require you to painstakingly and personally add, delete, edit, or intuit what medications the patient is currently taking. In reality, this is an algorithmic process that drains the psychiatrists of their time and attention during a medical encounter. Data entry—especially laborious medication data entry—is typically off-loaded to lesser trained personnel other than the physician.

So why do highly trained professionals so often default to engaging in this process? It usually boils down to a few inefficiencies that can be assessed by these questions:

Is your system collecting medication information that only a psychiatrists can input?
Does your office staff understand their roles in preparing the chart?
Are patients given clear instructions on how to provide essential information ahead of time?

Medications and allergies are completely and correctly entered and reconciled before the psychiatrists begins the encounter in over 90% of new patient encounters each month.

Medications and allergies are completely and correctly entered and reconciled before the psychiatrists begins the encounter in over 90% of established patient encounters each month.

Patient preferred pharmacy is listed in over 90% of all encounters.

Sample Goals

These goals aren’t just benchmarks—they’re a rallying point for your entire team. Everyone, from the front desk to the clinical staff works toward the same objectives, creating a more coordinated and efficient practice.

Step 2: Design a Charting Process That Works for Everyone

Improving your workflow requires a combination of automation, delegation, and oversight. Let’s break it down.

Use Your Patient Portal to Your Advantage

One of the easiest ways to reduce your workload is to let patients have ownership over some of their data input. Through your patient portal or check-in system, patients can enter their medications, allergies, and preferred pharmacy details before their appointment.

This doesn’t just save time for you—it engages patients in their own care, making them active participants in the process.

Tips for Charting Success:

Send clear messages: Patients are more likely to use the portal if they know how and why it matters. Consider sending reminders that explain the benefits of completing their information ahead of time.
- KPI: What percentage of patients respond to these messages?
Make access simple: Complicated logins can derail even the best intentions. Ensure your portal is user-friendly and easy to navigate.
- KPI: How many patients successfully log in before their visit?
Focus on key data: Once patients are logged in, the process should guide them to enter medications, allergies, and pharmacy details without friction.
- KPI: How many patients provide complete and accurate information?

If your practice uses a check-in module, it can act as a backup to collect any missing information, adding another layer of reliability to your system.

Delegate Responsibility to Your Team

Even with a well-functioning patient portal, some information might slip through the cracks. That’s where your staff comes in.

Train your front desk or medical assistants to review charts before the encounter. If something’s missing—whether it’s a new medication or an updated allergy—they can address it before you step into the room.

This ensures that by the time you’re face-to-face with the patient, you have everything you need to focus on delivering care.

Monitor and Adjust

No system is perfect right out of the gate. Review KPIs regularly to see how your process is working. If your practice isn’t meeting its goals, identify the bottlenecks and adjust.

For example:

Are patients finding your portal difficult to use?
Is your staff overwhelmed with last-minute data entry?

By addressing these issues early, you can fine-tune your system until it runs smoothly.

Step 3: Simplify Prescription Writing

Once medications are reconciled, the next step is to streamline the prescription process itself. Writing a prescription shouldn’t feel like navigating an obstacle course.

Here’s what you need at your fingertips to make it seamless:

Allergy Information: To avoid adverse reactions.
Current Medications: For quick reference and drug interaction checks.
Pharmacy Details: To ensure the prescription goes to the right place.
Patient Demographics: For accurate dosing.
Insurance Data: To help patients avoid unnecessary costs.

Well-designed EHR software should gather this information in advance, and include features such as advanced medical charting templates, to allow you to focus on selecting the right medication and completing the prescription with minimal clicks.

Lessen the Burden of Prescription-Writing

Optimizing medication management is more than just a time-saver—it’s a way to improve patient care while reducing your cognitive load. When your process is efficient, your attention shifts back to where it belongs: the patient in front of you.

By setting clear goals, leveraging automation, and involving your team, you can create a workflow that benefits everyone. And once it’s in place, the system run by the right EHR software largely runs itself, leaving you free to focus on what truly matters.

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Dr. Lawrence Gordon, MD

He is a practicing Otolaryngologist and the founder of ENT Specialty Care located in Goshen, NY. He is also the CEO and Founder of WRS Health. The software is an all-in-one platform, designed by physicians, providing clinician-centered workflow solutions to continually improve and grow your practice.