Page 20 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

» Teaching about disease state or treatment

recommended, including educational material given

» Review or instruction about home-care programs,

including any instruction provided to the patient’s

family or primary caregiver

☐ Follow-up instructions and all appointments made,
including referrals

☐ Each prescription and refill with drug name, dose,
frequency, and name and initials of prescribing provider

» If staff completes this on behalf of the provider,

identify “per provider” with the name of provider
giving verbal order

» Document the medicine’s purpose on the prescription
as well as the medical record

☐ Provider’s name and date of review on all lab, radiology,
and consultant reports

☐ All immunizations (or history of immunizations for adults);
the documentation should include:

» The date the Vaccine Information Sheet (VIS) was

given and the publication date of the VIS, which
appears on the bottom of the sheet

» Written parental or patient consent (or refusal) to

vaccinate, after receiving and reviewing a copy of the
most current VIS available for that vaccine

☐ All injections, including dosage, site, route, manufacturer,
lot number, date, and the name of the person administering

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