I am doing research on the documentation of medications in the medical record and I am wondering if anyone out there can give me advice and/or guidance.

When documenting prescriptions medications in a patients medical record is it required to document the instructions? I say yes but can not really find any documentation to support this. There are alot of different opinions on this here at the practice. Some say "no, just need the medication name, patient has been given instructions." Some say " it is assumed that if I write this drug name that one drop is to given x amount of times."

Are there documentation classes available somewhere that I can attend to learn the ins and outs of documentation.

I would like actual documentation to support one way or the other.

Thanks for all your time and help!