Memo - Documentation of Medications
Documentation of Medications
During the course of reviewing run reports, I often encounter “see list” or “various” or “too many to list” in the medications section of the PCR. This is not helpful when reviewing reports because it limits our ability to discuss the call in depth and is not considered accepted medical practice. If we want to be accepted as professionals, documentation should be complete and accurate. I would like to see the patient’s medications listed in the MEDICATION section and in the medical history or past medical history list ailment or conditions. This information should correspond with the Medication Section. If you are not sure what the medication is for, I would like you to look it up when you get back to the station!
If the medication is an antibiotic, find out about the recent visit to their physician; what symptoms, diagnosis, new symptoms, etc.
In addition to prescribed medications, please inquire about over-the-counter (OTC), herbal supplements and recreational drugs. Please document these also in the medication section and discuss them in the narrative section IF they are pertinent to the patient’s situation.
If you have questions or need clarification reference this correspondence, please do not hesitate to bring them up during one of our numerous Station Medical Director meetings.