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Medication Order - Content

Does every medication order need to contain a diagnosis, condition, or indication-for-use?  

Any examples are for illustrative purposes only. 

No. Standard MM.04.01.01 requires that a diagnosis, condition, or indication for use exists for each medication ordered. However, the indication can be anywhere in the medical record and need not be part of the order itself. For example, the indication may be part of the medical history, in the form of lab values, diagnoses, progress note entries, etc. 

However, standard MM.04.01.01. EP 2 requires organizational policy to designate when an indication for use is required as an element of a specific medication order.  For example, an order written as 'Acetaminophen 650 mg po q4h prn for fever greater than 101' clearly defines the indication when it would be appropriate to administer this medication.  
Manual: Critical Access Hospital
Chapter: Medication Management MM
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on October 26, 2021

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