Page 27 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

prescription and identification of the authorizing provider (i.e.,

MD signature or staff note indicating “per Dr. Smith”).

 Discuss risks, side effects, benefits of, and alternatives to

prescribed medications with the patient and document this

discussion in the record.

 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.

 Educational material should be provided to the patient if

available. Educational handouts are available for the patient’s
high alert medications by visiting the Consumer Med Safety

website.
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The Importance of Documenting Family History

CASE STUDY

A 32-year-old female patient presented to OB with presence of

palpable breast mass which ultimately was found to be
malignant. Upon medical record review, the description of the

breast mass was poor. The only statement describing the mass
was that it was located at the 4 o’clock position. There was no

mention of the patient’s menstrual history or family history with
respect to cancer. The patient’s mother and maternal

grandmother both had breast cancer. No consideration was

4 http://www.consumermedsafety.org/tools-and-resources

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