Page 26 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

applicable. Note the actual chart dates reviewed rather than simply

stating that you “reviewed the old chart”.

Basic Guidelines for Documenting Medications

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

 Update the medication history at each office visit.

 Communicate with other providers treating 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.

 Review and update allergies at every visit and whenever new

medications are prescribed.

 Do not prescribe medications without reviewing the record.

 Implement the use of a medication flowsheet:

 Keep it in the record separate from the progress notes.

 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

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