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Medication Order - Content1

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

Yes. Standard MM.04.01.01 requires that there be documented justification for all medications ordered. That justification can be in the form of lab values, diagnoses, progress note entries, etc. In other words, the documented justification must be evident somewhere in the medical record. Standard MM.04.01.01. EP 3 requires organizational policy to designate whether or when indication for use is required as an element of a medication order (e.g., PRN orders). In this situation, organizations must be in compliance with policies.
Last updated on April 11, 2016
Manual: Home Care
Chapter: Record of Care Treatment and Services RC

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