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Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient's current medications
HCPCS code
Name of the Procedure:
- Common Name: Medication Review
- Technical/Medical Term: Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient's current medications (G8427)
Summary
This procedure involves a clinician reviewing and updating a patient’s current list of medications. The clinician ensures that all medications, including prescriptions, over-the-counter drugs, and supplements, are accurately documented in the patient's medical record.
Purpose
- Medical Conditions/Problems Addressed: Ensures accurate documentation and prevents medication errors.
- Goals/Expected Outcomes: Enhances patient safety, improves medication management, and supports better clinical decision-making.
Indications
- Symptoms/Conditions: Patients on multiple medications, recent hospital discharges, new diagnoses, or changes in treatment plans.
- Criteria/Factors: Chronic diseases management, complex medication regimens, and patient history of medication non-adherence.
Preparation
- Pre-procedure Instructions: Patients should bring all current medications, including prescriptions, over-the-counter drugs, and supplements, to the appointment.
- Diagnostic Tests/Assessments: No specific tests required prior to the review.
Procedure Description
- Initial Patient Interaction: The clinician asks the patient about their current medications.
- Documentation: The clinician updates the medical record to reflect all current medications the patient is taking.
- Verification: The clinician verifies the list against any existing records or recent prescriptions.
- Education: The clinician may educate the patient on proper medication use and address any concerns or questions.
- Tools/Equipment: Electronic Health Record (EHR) system, medication list forms.
- Anesthesia/Sedation: Not applicable.
Duration
- Typical Duration: 10-20 minutes
Setting
- Location: Physician’s office, outpatient clinic, or during a hospital visit.
Personnel
- Healthcare Professionals Involved: Primary care physicians, specialists, nurse practitioners, and physician assistants.
Risks and Complications
- Common Risks: Minimal; primarily involves clerical errors that could be rectified promptly.
- Rare Risks: None significant; risks are typically related to pre-existing conditions or incorrect patient information.
Benefits
- Expected Benefits: Improved medication safety, better patient outcomes, and reduced risk of adverse drug events.
- Realization Timeline: Immediate to short-term improvements in medication management.
Recovery
- Post-procedure Care: No specific post-care required; patient continues with regular activities.
- Recovery Time: Not applicable.
- Restrictions/Follow-up: None, unless changes to medication are made.
Alternatives
- Other Treatment Options: Periodic pharmacy reviews, automated medication reconciliation systems.
- Pros and Cons of Alternatives: Alternatives like pharmacy reviews provide additional professional insight but may not be as integrated into the patient's overall care plan.
Patient Experience
- During the Procedure: Patients should feel comfortable and encouraged to discuss their medications and any concerns.
- After the Procedure: Patients typically experience reassurance in understanding their medication regimen better and have increased confidence in their treatment plan.
- Pain Management/Comfort Measures: No pain or discomfort; however, clear communication and patient education enhance comfort.