1159F Medication list documented in medical record (COA)

Name of the Procedure:

Medication List Documented in Medical Record (COA)

Summary

This procedure involves documenting a comprehensive list of all medications a patient is currently taking in their medical record. This list includes prescription drugs, over-the-counter medications, supplements, and herbal products.

Purpose

• Addresses: Ensures accurate medication management and avoids potential drug interactions or duplications.
• Goals: Improve patient safety, enhance the effectiveness of treatment plans, and facilitate clear communication among healthcare providers.

Indications

• Symptoms/Conditions: Patients with chronic conditions, multiple medications, recent changes in medication, or upon hospital admission and discharge.
• Criteria: All patients, especially those at risk for drug interactions, admitted to healthcare facilities, or undergoing significant medical treatments.

Preparation

• Instructions: Patients should bring a list of all current medications, including dosages and frequency. If possible, they should bring the actual medication containers.
• Assessments: A thorough review of the patient’s medical history and current medication usage.

Procedure Description

1. Initial Consultation: A healthcare provider interviews the patient to record all medications being taken.
2. Review and Verification: The medications listed are reviewed for accuracy and completeness.
3. Documentation: The information is documented in the patient’s medical record, either in written form or entered into an electronic medical record (EMR) system.
4. Cross-Checking: The medication list is cross-checked against current prescriptions and any other medical records available.
5. Follow-Up: Any discrepancies are clarified with the patient or their pharmacy.

Tools: Patient’s medication containers, medical record system or EMR, and standard documentation forms. Anesthesia: Not applicable.

Duration

Approximately 15-30 minutes.

Setting

Performed in various healthcare settings, including hospitals, outpatient clinics, and doctor’s offices.

Personnel

• Primary Care Physicians
• Nurses
• Pharmacists
• Medical Assistants

Risks and Complications

• Common: Minimal; risk mainly involves inaccurate documentation.
• Rare: Potential for miscommunication leading to medication errors.

Benefits

• Expected Benefits: Accurate and comprehensive medication records, reduced risk of drug interactions, and better-coordinated care.
• Onset: Immediate realization upon documentation.

Recovery

Not applicable, as this procedure is non-invasive and involves documentation only. No downtime or physical recovery is needed.

Alternatives

• Pharmacy Review: A thorough medication review conducted by a pharmacist.
• Patient Self-Documentation: Patients maintain their own up-to-date medication lists.
• Pros/Cons: Pharmacy reviews can be more detailed but may not integrate as seamlessly into medical records. Self-documentation relies heavily on patient accuracy and diligence.

Patient Experience

• During Procedure: Patients engage in a conversation and provide detailed information about their medication regimen.
• After Procedure: Minimal discomfort, with peace of mind that their medications are accurately documented.
• Pain Management: Not applicable, as the procedure is non-invasive.