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Don't overdose on medication order indications

Pharmacy Regulation Resource, May 12, 2004

You do not need to document an indication for use on each medication order as long as it exists somewhere in the patient's medical record.

JCAHO medication standard MM.3.10 requires a documented diagnosis, condition, or indication for use for each medication ordered. But that documentation could be located anywhere in the patient's chart, including the history and physical (H&P) or progress notes.

Indications for use usually exist somewhere in the patient's chart, says Bud Pate, REHS, a consultant with the Marblehead, MA-based The Greeley Company, a division of HCPro.

For example, if a patient has the diagnosis "diabetes" listed in the H&P, any medication ordered that caregivers typically prescribe for diabetes would meet the standard, says Greeley consultant Steve Bryant. The diagnosis of diabetes explains why someone prescribed the medication.

Including an indication in every order could be confusing for nursing staff, Pate says. Nurses at some hospitals have confused routine orders for PRN-or as needed-orders if prescribers include requirement for use, he says.

Tip: Require indications on orders for drugs that may have multiple uses, such as Benadryl or Tylenol.

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