Wiki Medication Documentation in Progress Note

[HeatherrLaw]

If a provider sees a patient and prescribes medication does the medication name need to be documented specifically in the assessment/plan section or can it just say medication sent to pharmacy because it is listed in the medication section of the office note.

 

[csperoni]

Here is what NGS has about prescription drug management:

1. Please define prescription drug management relative to MDM.
   
   Answer: In order to count prescription drug management there must be documentation of at least one of the following factors:
   1. A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient.
   2. Documentation on the prescription drug(s) that are being considered and the reason why they are being considered.
   3. Documentation of a decision to initiate a new prescription drug(s).
   4. Documentation of a practitioner’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition.
   5. The patient condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.

Prescription drug management is based on the documented evidence that the provider has evaluated medications during the E/M service as it relates to the patient’s current condition. Simply listing medications that patient takes is not prescription drug management. Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place in regard to those medications.

Without the name of the medication, how would you know it is an actual prescription medication and not an OTC med sent to pharmacy that may be covered under prescription benefits? Some prescription plans will cover OTC meds when filled/purchased this way. From any EMR I've used, the information (name, dosage, directions) will automatically populate into the note to save redundant provider work.
If it was only one note like this, I would give low MDM. If it is a recurring issue, I would discuss with the provider and/or EMR vendor to figure out where the disconnect is occurring. If the provider is doing the work of evaluating a prescription drug, dosage and instructions, I want to give them the credit for moderate risk. However, I can only do so if the work is DOCUMENTED.