Wiki Data reviewed- Level of Risk

[PGADDY]

Patient has two chronic stable conditions. No tests ordered or reviewed. Physician states continue meds as ordered. Medications are not documented under current assessment and treatment, but are listed in the medication list under history, ROS, etc. Does the physician need to state the medications and dosage in their documentation to be counted or is just being listed sufficient. Current discussion in outpatient setting. Physician assigned a level 4.

 

[Cls1530]

Yes, the physician needs to be actively managing those medications and not just documenting them. The guidelines say "prescription drug management" and just having them in the medication list does not show management.