Medication Documentation

Medication documentation is about how medication decisions are recorded, communicated, validated, implemented, supported and followed. It promotes safe, effective and appropriate drug therapy as part of patient-centred care. The Medication List is a record of medications in active use by a given patient at a given time.

Ongoing maintenance and periodic review of a comprehensive medication list is essential for clinical decision support, medication administration, adverse reaction surveillance, patient education, patient adherence and system-to-system health record transfers.

The collection of the best possible medication history occurs in both outpatient and inpatient workflows. Reconciliation of prior with new medications occurs at care transitions (e.g., admission, discharge, transfer) as well as periodically during ongoing disease management.

Good practice is reflected by clear documentation of any variance between intended and actual medication use and any reasons for change from prior to temporary or ongoing new medication lists.

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