Documentation

Documenting HDS information in her medical record

Answer

Please review the following example of correct documentation for Mrs. Nguyen in her chart note.

1. Raw Garlic

Patient using daily raw whole garlic cloves. Dose: ingesting 3-4 gloves a day around lunch time. She does not take garlic with other medications. Reason: lowers her cholesterol. Discussed risks and benefits of garlic with patient. It is a potential cause of her bruising. Recommend she decrease her dose and only use one clove daily.

2. Beauti-Leaf Diabetee-Care Tea

Multiple ingredient product from China. Not properly labeled or ingredients documented.
Ingredients include: Astragalus, Ginseng, Licorice, Poria cocos, morus alba, orhio pogon

Discussed risks and benefits of tea with patient. Would recommend she stop tea as there is a possible interaction with the patient's metformin. Also concerns about quality and quantity of ingredients in package.