Page 42 - APP Collaboration - Assessing the Risk (Part Two)

SVMIC Advanced Practice Provider Collaboration: Assessing the Risk

MEDICATION

☐ Obtain a complete medication history at the first office visit
and update the medications at every patient encounter.

☐ EHR: Use care to verify that the correct medication and
correct dose have been selected before entering the
medication in the system or transmitting to pharmacies.

☐ Note any medication alert in the record and document
how it was addressed, or why it was overridden.

☐ Closely monitor chronic or high-risk medications by
creating alerts or triggers to ensure appropriate follow-up.

☐ Utilize only standardized abbreviations. Patients are often
under the care of multiple medical providers and confusion
can thereby be avoided.

☐ Engage in a thorough discussion of medication therapy,
document the details of the discussion and the educational

materials provided.

☐ Obtain written informed consent as appropriate for some
chronic and high-risk medications. Remember, some states
require it for opioid therapy.

☐ Communicate with other treating providers to correlate
therapies.

DOCUMENTATION

☐ Document all clinical communications with patients,
including telephone calls (during and after-hours) and

electronic communications (email, text, portal).

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