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SVMIC Risk Basics: Systems
3. Communicate with other providers treating the patient to correlate
therapies and decrease the possibility of drug interaction or
incompatibility.
4. Document allergies or a notation of “No Known Allergies” in a
conspicuous manner (clearly flagged) and consistent location
throughout the record.
5. Document a description of any reported allergic reaction or
intolerance.
6. Do not prescribe medications without reviewing the record.
7. Implement the use of a medication flowsheet:
a. To be kept in the record separate from the progress notes.
b. Document regular and “PRN” medications, over-the-counter
medications, vitamins, or supplements.
c. Document a start and stop date for each.
8. Document each prescription issued and each renewal, whether in
the office or over the phone. Include the medication name, strength,
route, frequency, duration of prescription, and identification of the
authorizing provider (i.e., MD signature or staff note indicating “per
Dr. Smith”).
9. Discuss risks, side effects, benefits of, and alternatives to prescribed
medications with the patient and document this discussion in the
record.
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