Page 28 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

» Document regular and “PRN” medications, over-the-

counter medications, vitamins, or supplements.

» Document start and stop date for each.

☐ Document each prescription given and each renewal,
whether in the office or over the phone (preferably on
the aforementioned medication flowsheet). 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”).

☐ Discuss risks, side effects, benefits of, and alternatives to
prescribed medications with the patient and document this
discussion in the record.

☐ When medications are prescribed in a manner contrary
to the manufacturer’s recommended use, the patient

should be so advised and the rationale for the decision to
prescribe should be documented.

☐ Document any educational material given to the patient.
Educational material should be provided to the patient

if available. Educational handouts are available for the

patient’s high-alert medications by visiting the Consumer
Med Safety website.
4

4 http://www.consumermedsafety.org/tools-and-resources

Page 28