What are the essential items to document during a follow-up visit for a patient with stable, chronic, and controlled medication (meds)?

From the Guidelines

When documenting a stable chronic controlled medication patient visit, it's essential to record the patient's current medications, vital signs, relevant physical examination findings, laboratory results, and patient education, as outlined in the most recent guidelines 1. To ensure comprehensive care, the following elements should be documented:

• Current medications with specific names, doses, and schedules
• Any reported side effects or adverse reactions
• Medication adherence patterns
• Vital signs, including blood pressure, heart rate, respiratory rate, and weight
• Relevant physical examination findings related to the condition being treated
• Laboratory or diagnostic test results that monitor medication effectiveness or potential toxicity
• The patient's subjective assessment of symptom control
• Any medication adjustments made during the visit
• The treatment plan going forward
• The follow-up timeline Additionally, documenting patient education regarding medications, lifestyle modifications, and consultations or referrals is crucial, as emphasized in the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline 1. This comprehensive documentation ensures continuity of care, facilitates medication management, provides legal protection, supports insurance reimbursement, and enables quality improvement by tracking outcomes over time, as highlighted in the study on medication reconciliation 1. Regular documentation of these elements helps identify trends in the patient's condition and response to treatment, allowing for timely interventions if the patient's status changes, and is in line with the principles of clear communication and coordination of follow-up care 1.

From the Research

Items to Document on a Stable Chronic Controlled Med Patient Visit

• Medication regimen:
  • Examine all medications being taken, whether prescription or not 2
  • Review each drug regimen in a systematic manner, noting history of adverse effects, need for the drug, duplication in therapy, inappropriate dose, route, or schedule, current adverse effects, drug-drug interactions, and drug-disease interactions 2
  • Ensure an accurate, easy-to-follow, electronically developed medication list 3
• Medication history:
  • Encompass all currently and recently prescribed drugs, previous adverse drug reactions including hypersensitivity reactions, any over-the-counter medications, including herbal or alternative medicines, and adherence to therapy 4
  • Accurate documentation of concomitant herbal or alternative therapies 4
• Control of chronic conditions:
  • Simultaneous control of hyperglycemia, blood pressure, and low-density lipoprotein cholesterol in patients with diabetes mellitus, hypertension, and hyperlipidemia 5
  • Less stringent goals may have a relatively large effect on the proportion achieving simultaneous control 5
• Continuity of medication management:
  • Reflecting interpersonal continuity and management continuity 6
  • May provide a means of identifying patients at high-risk of adverse events 6
  • Potential target for future intervention to improve care delivery among multiple chronic condition patients 6