Page 27 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

The review should include the quality and completeness of

documentation, as well as accurateness and continuity of care.
Additionally, the entire practice should conduct a review using

standardized criteria.

Basic Guidelines for Documenting Medications

Medication errors continue to occur with alarming frequency.
Many of these errors are preventable by observing some basic

documentation guidelines:

☐ Document a complete medication history at the first office
visit.

☐ Update the medication history at each office visit.

☐ Document communication with other providers treating
the patient to correlate therapies and decrease the

possibility of drug interaction or incompatibility.

☐ Document allergies or a notation of “No Known Allergies”
in a conspicuous manner (clearly flagged) and consistent

location throughout the record.

☐ Document a description of any reported allergic reaction.

☐ Review and update allergies at every visit and whenever
new medications are prescribed.

☐ Do not prescribe medications without reviewing the
record.

☐ Implement the use of a medication flowsheet:

» Keep it in the record separate from the progress
notes.

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