How is your organization addressing Med Rec in the outpatient setting? Our providers are concerned with completing an accurate Med Rec, as well as, the Regulatory and Legal implications if incorrect/or missing a medication.
Could you let me know how your organization views and completes the Outpatient Med Rec?
EP 1: Obtain information on the medications the patient is currently taking when they are admitted to the hospital or is seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications.
Note 1: Current medications include those taken at scheduled times and those taken on an as-needed basis. See the Glossary for a definition of medications.
Note 2: It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information from the patient and/or other sources will be considered as meeting the intent of the EP.
Do you complete Med Recs for all outpatient visits i.e. Radiology, OT/PT, Nutrition, Nurse only visits? Is it required for all visits regardless of visit type? Or only for physician/provider visits?
Thank you for any information you can provide.