Page 26 - Risk Reduction Series Effective Systems Part 2

SVMIC Risk Reduction Series: Effective Systems

8. Implement the use of a medication flowsheet:

a. To be kept in the record separate from the progress
notes.

b. Document regular and “PRN” medications, over-the-

counter medications, vitamins, or supplements.

c. Document start and stop date for each.

d. Discontinued medications should be appropriately
notated as such without removing them from the

medical record

9. 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”).

10. Discuss risks, side effects, benefits of, and alternatives to

prescribed medications with the patient and document
this discussion in the record.

11. 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.

12. Educational material should be provided to the patient

if available. Educational handouts are available for
your patient’s high-alert medications by visiting: www.

consumermedsafety.org/tools-and-resources/medication-
safety-tools-and-resources.

13. Do not prescribe unfamiliar medications. Physicians should
be aware of current information and guidelines governing

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