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How to create a complete patient medication list

Ambulatory Safety Monitor, May 20, 2004

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Make sure medication lists are always in the same location in the patient charts, perhaps attached to the front or back cover, says Kim Weber-Chandler, RN, patient safety coordinator for Gundersen Lutheran Health Systems, a group of hospitals and ambulatory clinics in Wisconsin, Iowa, and Minnesota.

A complete medication list should include the following:

• Drug name (generic if appropriate)
• Dose
• Route of administration
• Frequency
• Reason for use
• Prescriber
• Refill status

To make sure your medication lists are accurate and complete, assign a nurse or medical assistant to randomly review the medication lists of approximately 50 patients.

Check to make sure that all medications the patients take are listed in the chart, and that no medications on the list have been discontinued.

Check the percent of charts that meet all of the above criteria, says Weber-Chandler. She also suggests setting high goals for the accuracy of the charts.

If your facility uses an electronic medical record, set up your system to check for duplicate drugs, drug interactions, and patient allergies.

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