Wiki Medication Refills

[irma011]

If the provider documents "needed refills were needed" but did not document WHAT medications they are, does this constitute as prescription drug management? or does there need to be documentation of exactly what medications were filled ? Thanks in advance!

 

[csperoni]

Without indicating what the medications were, I would not count this as prescription drug management. It could have been OTC meds.
Most EMRs I have seen will automatically populate into the note when the physician enters the refill. If your system does not/cannot (or you are on paper, or papyrus, or cave drawings ), I would consider this first instance a learning process and educate my provider for moving forward.

 

[Karalea88]

Patient sees provider, meds are reviewed and one prescription has been discontinued but it does not state if the provider was the one to discontinue the medication. Would this still count as prescription drug management since discontinued medication is listed under plan? Or would this be considered under history since it also looks like the patient's medication list was just updated?

 

[csperoni]

If it's not documented, I would not count it. This is another opportunity to educate my providers.

 

[Karalea88]

Thank you. Only stating continue current therapy/medication would be treated the same way since medication needed to be continued is not documented, correct?

 

[csperoni]

If the note said "continue medication" I would count it. If the note said "discontinue medication" I would count it. If the note said "medication has been discontinued" I would not count it.
It just needs to be clear that this clinician provided the medical decision making, not just updating records based on another clinician's medical decision making.