Question

True or False?

The ability to specify in a discrete field that the patient takes no medications

List to include only medications entered by the current prescriber

Provide the ability to enter only coded medications from a standard medication list

The ability to mark a medication as "erroneous" or "discontinued"

Answer 1

False, There is no discrete field to specify that patient takes no medication.In a condition if the patient not takes the prescribed medication it should be documented in a highlighted format in the patient progress chart and also verbally informed to the physician.After that the physician will discuss with the patient about compliance with medication even then, the patient not willing to take the medications then it should be mentioned as AMA (Against medical advice) there you can specify the patient takes no medications.It means initially itself you can't take it as AMA or as discrete field.

The medications should be prescribed by the physician that he is a independent prescriber.Also it can be done by the supplementary prescriber that is the professional who is also involved in patient care. It can be a nurse,midwife or pharmacist.But they are limited for prescribing certain medication only.So always the current prescriber is the physician.

While coding medications from the standard medication list ,code the medication code given by the NDC (National Drug Code) .You can enter the medications if it has all necessary information .It includes generic name, validity of medication list, type,dose and  route and it must be prescribed by the authorized prescriber. It is the ability of the drug to be enter.

In the patient chart , in medication chart the drug should be highlighted as stopped or with hold for the discontinued medications.For avoiding confusion remove all discontinued medication or prepare new medication chart which has only the current medications of the patient.For erroneous medication , if any medication is suspect as wrong then immediately confirm it with the physician.Review the medication chart carefully update it by this can avoid taking the erroneous medications.The drug is marked as discontinued when it is a order given by the physician.It should be mentioned in the patient chart then only the nurse can make change in the patient medication chart.The drug is considered as erroneous when it is suspect by the professional and confirmed by the prescriber only then it is taken as erroneous.