Page 7 - Hospitalists - Risks When You're the Doctor in the House (Part Two)
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SVMIC Hospitalists - Risks When You’re the Doctor in the House
Guidelines for Reducing Risk of a Medication
Error Claim
Take a complete medication history.
Update the medication history as necessary.
Communicate with other providers regarding the treatment
of 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 or
intolerance.
Review and update allergies and medication intolerances
whenever new medications are prescribed.
Do not prescribe medications without reviewing the
record.
Implement the use of a medication flowsheet:
» Keep separate from the progress notes in the medical
record.
» Document regular and “PRN” medications, over-the-
counter medications, vitamins, and supplements.
» Document start and stop date for each.
» Discontinued medications should be appropriately
notated as such without removing them from the
medical record.
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