business of Medicine
Onboarding Practice Managers Toolkit
Maintaining a medication list in the medical record
Accurate medication records are central to delivering safe, effective clinical care. Drug-drug interactions, drug-disease interactions, incorrect doses, omissions and duplications are often attributed to outdated and incomplete medication lists. In emergency situations, medical records may serve as the only source of information on a patient’s medications, thereby performing a critical function in that person’s care.
Furthermore, medication lists represent one of the most important components of an electronic health record (EHR) since they are used for filling refill requests, assessing quality, performing research, and for informing computerized clinical decision support.
Maintaining accurate medication records is a challenge. A multitude of factors such as patients’ lack of knowledge of their medications, physician and nurse workflows, and lack of integration of patient health records across the continuum of care — all contribute to a lack of complete medication reconciliation. In addition, patients change their medications frequently, often visit more than one physician and may use undocumented over-the-counter medications. Both patient and provider interventions are necessary to facilitate a collaborative approach to medication management.
The process recommended for providers to maintain the most complete and accurate list possible of a patient’s current medications is known as “medication reconciliation”.
Medication reconciliation is a formal, standardized process that includes the following steps:
- Develop a medication form or format most workable for your group.
- Engage the patient in the process
- At each patient visit obtain a complete, accurate list of the medications the patient is taking, and compare this list to the list documented in the medical record.
- Ask the patient about medications he/she may be taking from other providers and add these to your list.
- Ask the patient about medications he/she may no longer be taking and delete these from your list.
A comprehensive list of medications should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions (hereafter referred to collectively as medications). Over-the-counter drugs and dietary supplements are not currently considered by many clinicians to be medications and thus are often not included in the medication record. As interactions can occur between prescribed medication, over-the-counter medications or dietary supplements, all medications and supplements should be part of a patient’s medication history and included in the reconciliation process, which in turn creates the potential for error.
Commonly overlooked medications include birth control pills, inhalers, eye drops, patches, herbal medicines and medications prescribed by other physicians. As you gather this information, ensure that each drug’s brand name, generic name, strength and frequency are documented with the current date.
- Provide the patient with an updated copy of his/her medication list after performing medication reconciliation at each visit.
- Look for opportunities to provide the patient with additional education about their medications.
With consistent and proper use, a simple medication list can become a very powerful part of the chart providing countless benefits, such as the following:
Efficient charting: Because the medication list can be updated via a few check marks, it makes documentation quicker and easier. Reviewing it at each visit requires less time than documenting each medication in the progress note. The physician can simply refer to the medication list in the note (“the medication list is reviewed today with the patient”), thus saving time and money in dictation costs.
Safer refills: When patients require prescription refills, the medication list makes it easy to check that the patient is receiving the correct prescription. Physicians and nurses do not have to search through pages of progress notes as the information is clearly displayed at the front of the chart.
Improved Communication with other physicians: The medication list can easily be photocopied and sent to other doctors involved in the patient’s care so they can see the patient’s medication history. This improved information-sharing between physicians can prevent dangerous medication errors.
Information recall: A patient’s medication list is often a snapshot of his or her medical history. Reviewing the medication list with the patient helps the physician recall past treatments. This is particularly helpful when a patient presents with a recurring problem.
Allergy documentation: Ideally, allergies should be documented in one place in the chart. What better place than the medication list? The allergy list should describe the type of reaction and include the date by each allergen.
An effectively maintained medication list through the process of medication reconciliation makes practicing medicine easier, may help facilitate improvements in the quality of patient care, and may also help reduce medication errors. While a perfectly accurate medication list cannot be attributed to a single intervention or tool, a collaborative approach involving education, accountability, and technology can go a long way in helping patients and their providers tackle the challenge of medication safety together.
Documenting medication administration in the office medical record
The administration of prescribed medications by authorized personnel should be conducted in a manner that assures:
1. Right patient
- Check the name on the order and the patient.
- Use 2 identifiers.
- Ask patient to identify himself/herself.
- When available, use technology (for example, bar-code system).
2. Right medication
- Check the medication label.
- Check the order.
3. Right dose
- Check the order.
- Confirm appropriateness of the dose using a current drug reference.
- If necessary, calculate the dose and have another nurse calculate the dose as well.
4. Right route
- Again, check the order and appropriateness of the route ordered.
- Confirm that the patient can take or receive the medication by the ordered route.
5. Right time
- Check the frequency of the ordered medication.
- Double-check that you are giving the ordered dose at the correct time.
- Confirm when the last dose was given.
6. Right documentation
- Document administration AFTER giving the ordered medication.
- Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.
7. Right reason
- Confirm the rationale for the ordered medication. What is the patient’s history? Why is he/she taking this medication?
- Revisit the reasons for long-term medication use.
8. Right response
- Make sure that the drug led to the desired effect. If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant?
- Be sure to document your monitoring of the patient and any other nursing interventions that are applicable.
These eight factors should be documented in the patient’s office medical record.
Staff should demonstrate competency in the administration and documentation of medications. Competency checks should be conducted on an ongoing basis; the results should be documented in each employee’s personnel file.
MagMutual Risk Management and Patient Safety Consultants invite our policyholders’ questions. If you wish to discuss issues related to this article, or have other questions please call us at 1-800-282-4882, and ask for Risk Management.
Reference: Nursing2012 Drug Handbook. (2012). Lippincott Williams & Wilkins: Philadelphia, Pennsylvania.
Document substance use
Document the patient's history related to patterns of use of alcohol and other substances. Unless patients are screened for alcohol and drug use disorders, providers are more likely to miss the opportunity to identify the problem and to incorporate this important information into the plan of care. Further, this is important clinical information to consider when prescribing medications.1
If the patient is at high risk for medication abuse or has a history or pattern of substance abuse, the physician should consider the use of a written agreement between physician and patient outlining patient responsibilities, including, but not limited to:
- performing urine/serum medication levels screening as necessary
- monitoring the number and frequency of all prescription refills
- discontinuing drug therapy when the agreement between patient and provider has been violated
- providing substance abusers with referrals to specialists, as needed and
- maintaining a copy of the written agreement in the medical record
Clinical Policies and Practices for Tobacco Use Cessation
Screen all clients for tobacco use and provide strategies if they are ready to quit.
- Document patient tobacco use, and the patient’s cessation attempts in the medical record.
- Ask the patient about tobacco use at all visits.
- Include tobacco use cessation in treatment planning.
- • Educate clients on the health dangers of smoking and about approaches to quitting (i.e., quit lines, medications, and counseling).
Patient Privacy and Record Confidentiality
The federal confidentiality law and regulations (codified as 42 U.S.C. § 290dd-2 and 42 CFR Part 2 (“Part 2”), enacted almost three decades ago after Congress recognized that the stigma associated with substance abuse and fear of prosecution deterred people from entering treatment, has been a cornerstone practice for substance abuse treatment programs across the country. Part 2 does permit patient information to be disclosed to Health Information Organizations (HIOs) 2 and other health information exchange (HIE) systems. However, the regulation contains certain requirements for the disclosure of information by substance abuse treatment programs; most notably patient consent is required for disclosures, with some exceptions.2
This consent requirement is often perceived as a barrier to the electronic exchange of health information. It is possible to electronically exchange drug and alcohol treatment information while also meeting the requirements of Part 2.
MAG Mutual Risk Management and Patient Safety Consultants invite our policyholders’ questions. If you wish to discuss issues related to this article, or have other questions please call us at 1-800-282-4882, and ask for Risk Management.
Related topics: Documentation
The information presented in this Advisory is intended as general information of interest to physicians and other healthcare professionals. The recommendations and advice published herein do not reflect or establish a standard of care and do not establish rules for the practice of medicine. The publication of this information is not intended as an offer to insure such conditions or exposures, or to indicate that MAG Mutual Insurance Company will underwrite such risks for the reader. Our liability is limited to the specific written terms and conditions of actual insurance policies issued.
1 National Institute on Drug Abuse, www.nida.nih.gov
2 Most substance abuse treatment programs are also subject to the HIPAA Privacy Rule. In 2004, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a guidance that summarizes variance between the two Rules and implementation solutions. That guidance can be found at http://www.samhsa.gov/HealthPrivacy/docs/SAMHSAPart2-HIPAAComparison2004.pdf.
Authorization for prescription renewals
It is recommended that providers establish reliable office policies for how prescription requests from patients will be handled. When staff members are authorized to provide refills pursuant to a written protocol, it is suggested that physicians sign off on all protocols before they are implemented. It is prudent to periodically review the protocols and maintain copies of any that are revised or discontinued.
Although the need for patients to obtain prescription refills is an inevitable part of any medical practice, it must be emphasized that clinical reviews are essential for safe medication prescribing. The decision to utilize written protocols should be weighed against the risks of a delay in a full medical assessment. The disadvantage is that this process may bypass opportunities to provide preventive care and can jeopardize patient safety.
Some issues to consider when establishing safe medication refill guidelines:
- Establish a timeframe for addressing all refill requests (i.e. 24, 48 hours)
- Establish the manner in which urgent requests will be handled (for example, they may be directed to the physician immediately)
- Identify the medications that are considered “urgent” medications, such as those for hypertension, asthma, seizures, diabetes.
- Identify non-urgent medications such as those prescribed for acne, allergy, and contraceptives.
- Identify the medications that require provider approval, e.g. controlled substances, oral steroids, and antibiotics.
- Establish restrictions for the number of times a refill may be issued and time frames when patients are expected to have monitoring visits before being given more refills.
Request #Supply may RxRefillsComments1st30 days Make appointment2nd15 days Make appointment;3rd7 days Make appointment4thnone Make appointment
You may also specify any laboratory information needed prior to refilling certain medications. See example below.
Medication;Labs/Information NeededRefills approvedDiabetic (Metformin, Insulin, Glipizide, Actos)BMP, Normal Cr, AIC90 days + 1 refill
It may be helpful to establish documentation requirements for the office staff for prescription refills. For example:
- The next scheduled appointment date and time
- The date of the last office visit and date of last prescription written for requested medication
- The date of the last well women exam for HRT or OCP requests
Other suggestions include:
- Provide sufficient drug quantities and refills to last beyond the next appointment.
- Update all prescriptions at every patient visit.
- Use EHR software to prompt sufficient refills and coverage verifications during the prescribing moment.
- Preload prescriptions with instructions to allow substitute dosage forms.
- If patients run out of medication before their next planned visit, investigate whether appointment-scheduling strategies are insufficient or drugs are being diverted.
- Avoid automatically writing a new prescription when a patient changes pharmacies. Pharmacists may transfer a prescription's remaining refills between pharmacies.1
Keep in mind that prescribing laws may vary from state to state and can change over time. Physicians are advised to check with their state board of pharmacy or health licensing board to determine the rules in their particular area.
The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.