An important aspect of medical records is the relationship between the medications which a patient is taking and the conditions for which a patient is being treated. It is imperative that any medication a patient is prescribed be supported by a documented diagnosis for a condition for which the patient is being treated. Often, a patient will be on an appropriate medication but an audit of the chart will show that the problem list, or Chronic Conditions list, will not contain a diagnosis which supports that medication’s use. This does not mean that the medication is inappropriate; it does mean that the record is incomplete.
The foundation of this part of the record is an accurate, up-to-date medication list with valid directions for the medication’s use, and a complete, accurate chronic conditions list. Once these two are present, it is important that each medication be associated with the diagnosis for which the medication is being given.
NextGen has made it possible to do this easily. The following tutorial explains the steps for formally associating medications with the diagnosis for which the medication is prescribed. It is an important part of your medical record.