How to Document Verbal Medication Consent using Keyphrases in Notes

In most situations, a separate, signed “Medication Consent” document is no longer required. Consents for medications can be captured/documented in the prescriber’s progress note. These recommendations are specific to consents for medications and not general informed consent/consent to treat.

To review the CalMHSA protocol and memo by Manatt, click here. You can also find the vetted templates and suggested use cases. 

  1.  Begin writing your note as normal. 
  2.  Click to place your curser in the Information and Education box in the Medication section of your note. 
  3. Click the Select Action icon in the upper right-hand corner. 
  4. Select Favorite Phrases from the menu. 
  1. A pop-up will appear named Use Key Phrases on the left side of your screen. Click the Agency tab.
  2. Click the Category drop-down.
  3. Select CalMHSA Key Phrases.
  1. Click the Use hyperlink under the appropriate phrase to insert into your note. (see table below for verbage). 
  1. You will then need to edit the text as needed,
    1. Currently, will need to manually add medication information/sig, though in near-future psych note template, can refer to a selected medication list.
    2. Side effects currently will need to be added manually.
    3. Keyphrases of general side effects for drug/drug categories could be created by user and/or counties and inserted with the medication consent keyphrase
  2. Continue to document as normal. 

Video Walk-Through