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What would you do if medication records were not legible?

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sheldrake | Student | eNotes Newbie

Posted August 20, 2009 at 11:51 AM via web

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What would you do if medication records were not legible?

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Lorraine Caplan | College Teacher | (Level 2) Senior Educator

Posted August 20, 2009 at 1:07 PM (Answer #1)

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I think we need more information to give you the help you need.  Here are some ways you can clarify:

Whose medication records are these?

What is your role that requires you to read these records?

Are these current records that need to be read to properly care for a patient? 

Most medication records today are maintained in an electronic form by pharmacies, doctors, and hospitals.  Are you sure there is no electronic form available to you?

Are you able to communicate with the physicians who wrote the prescriptions for these medications?  If so, that is certainly the simplest solution.

Under no circumstances should you or anyone else try to make a guess about medication records and allow someone to take medication on the basis of your guess. 

 

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krishna-agrawala | College Teacher | (Level 3) Valedictorian

Posted August 20, 2009 at 3:36 PM (Answer #2)

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Point made in the previous answer about need for more information to be able to decide exact course of action is quite appropriate. However this is one important issue that needs to be highlighted in every situation. Whatever be the reason for medication record not being legible, and whatever the difficulty in getting the correct and complete information, it most important that further treatment is not carried out on the basis of incorrect information assumed on the basis of illegible records. Whatever action needs to be taken to get the required information, must be taken and correct information must be obtained.

Also there is a the principle of "a stitch in time saves nine". As soon as you have the opportunity to examine the records, it is best to ensure that you are able to read and understand. For example, when a doctor writes a prescription, it is best to examine it and make sure you understand it when the doctor hands it over to you, rather than discover later that it is not legible.

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mapriem | High School Teacher | (Level 3) Adjunct Educator

Posted August 24, 2009 at 11:49 PM (Answer #3)

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If you are talking about handwritten entries into your medical record, the first thing is to consult with your physician about the need for computer records and switch doctors if necessary. One can also contact the pharmacy where the medications were purchased and request a history of your pharmaceutical records.  It is also very advisable for you to keep a history of your own medical records in an excel program on your computer for easy access. This way you can have the dates, name of medication, strength of dose, and name of doctor any time to print out and give at a hospital visit or change of doctor.

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