Certified Medical Assistant (CMA AAMA)Communication and Legal/EthicalMedium
A medical assistant is updating a patient's medication list in the electronic health record (EHR). The patient states they stopped taking a prescribed medication three months ago due to side effects. How should the medical assistant document this information?
- ADelete the medication from the active list and note 'discontinued'.
- BInform the physician immediately before documenting any changes.
- CMark the medication as 'inactive' and add a note about the patient's reason.
- DDocument 'patient non-compliant with medication' in the progress notes.
Show answer & explanationAnswer & explanation
Correct answer: C. Mark the medication as 'inactive' and add a note about the patient's reason.
When a patient discontinues a medication due to side effects, the medical assistant should mark it as inactive and document the patient's stated reason. This ensures an accurate and complete medication history while providing context for the discontinuation.
Why the other options are wrong
- A. Deleting the medication entirely removes valuable historical data about what was once prescribed.
- B. While informing the physician is important, documentation of the patient's statement should happen first to ensure accuracy.
- D. Labeling a patient as 'non-compliant' is judgmental and does not accurately reflect the patient's reason (side effects).
Medication Reconciliation
The process of creating the most accurate list possible of all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing it against the physician's orders.
- Helps prevent medication errors.
- Should be done at every transition of care.
- Includes prescribed, over-the-counter, and herbal medications.
Memory trick: Accurate, Active, and Always with a Reason.