Page 19 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

 All pertinent discussions with the patient and family

members

 Notification of test and results

 Informed consent and informed refusal discussions

(including any educational material given and

reviewed)

 Teaching about disease state or treatment

recommended, including educational material given

 Review or instruction about home-care programs,
including any instruction provided to the patient’s

family or primary caregiver

 Follow-up instructions and all appointments made, including

referrals

 Each prescription and refill with drug name, dose, frequency

and name and initials of prescribing provider

 If staff completes this on behalf of the provider, identify

“per provider” with the name of provider giving verbal

order

 Document the medicine’s purpose on the prescription

as well as the medical record

 Provider’s name and date of review on all lab, radiology and
consultant reports

 All immunizations (or history of immunizations for adults); the

documentation should include:

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