Chapter 6: Documenting Medications Flashcards
The patient’s medical record should include a medication history that encompasses?
All currently prescribed drugs, previous adverse drug reactions, over the counter medications and the patient’s response to therapy.
The patient’s medications are located in?
Histories and physicals, Progress notes, Discharge summaries, Medication lists.
Why providers must take care when reviewing medications in the electronic health record?
Copy and paste allows to duplicate information across different records, easy to move previous medications forward into the new note.
Why a MA must be diligent when reviewing the patient’s health record?
To make sure the information is still appropriate and tells the story of the patient’s current condition.