Chapter 6: Documenting Medications Flashcards

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1
Q

The patient’s medical record should include a medication history that encompasses?

A

All currently prescribed drugs, previous adverse drug reactions, over the counter medications and the patient’s response to therapy.

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2
Q

The patient’s medications are located in?

A

Histories and physicals, Progress notes, Discharge summaries, Medication lists.

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3
Q

Why providers must take care when reviewing medications in the electronic health record?

A

Copy and paste allows to duplicate information across different records, easy to move previous medications forward into the new note.

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4
Q

Why a MA must be diligent when reviewing the patient’s health record?

A

To make sure the information is still appropriate and tells the story of the patient’s current condition.

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