What is the correct action if there is incomplete documentation for post-discharge medication review?

Requesting additional documentation or a follow-up review is essential when there is incomplete documentation for post-discharge medication reviews. Comprehensive documentation is critical for ensuring patient safety and the effectiveness of care transitions. Incomplete information can lead to potential medication errors, misunderstandings about the treatment plan, and could compromise the quality of the patient’s ongoing care.

By seeking additional documentation or conducting a follow-up review, healthcare providers can verify that the patient understands their medication regimen, clarify any uncertainties, and ensure that any changes in medications during the hospital stay are properly communicated and understood by the patient. This practice aligns with the overall goals of HEDIS, which emphasize the importance of high-quality healthcare delivery through effective communication and thorough documentation. This approach helps to prevent adverse events and enhances the continuity of care.