Chapter 6: Documenting Medications Flashcards
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.
2
Q
The patient’s medications are located in?
A
Histories and physicals, Progress notes, Discharge summaries, Medication lists.
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.
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.
