Page 25 - Risk Reduction Series Effective Systems Part 2

SVMIC Risk Reduction Series: Effective Systems

face-to-face counseling by the physician or nurse. Educational

materials should be available for immediate printing to
supplement your discussion and documentation. Many EHRs

have a pre-programmed default to prompt discussion and print
materials. Monitoring and follow-up appointments for a patient

on chronic medications should be outlined to meet the patient’s
expectations. Finally, it is important that these educational

efforts, along with the patient’s understanding of the vital role
they play in his or her therapy, are documented in the medical

record.

Guidelines for Reducing Risk of a Medication

Error Claim

1. Take a complete medication history at the first office visit.

2. Update the medication history at each office visit.

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. Review and update allergies and medication intolerances

at every visit and whenever new medications are
prescribed.

7. Do not prescribe medications without reviewing the
record.

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