What should I record in medication compliance tracking?

This will depend on what is happening with your patient. Each of the options are discussed below:

Compliance:

This should be checked if the patient is being prescribed medication and reports that they are taking it as prescribed routinely.

Noncompliance

This should be checked if the patient is being prescribed medication and reports that they are not taking as prescribed. This may be someone who has self adjusted the time that they are taking it, have self adjusted the dose, or has discontinued a medication wihtout medical advice. It is usually advisable if any of these exist to document it in the progress note field and make a referral to contact the psychiatrist or prescribing PCP.

Side Effects

This is checked if the patient reports the presence of any side effects related to taking the medication. It is usually advisable to record the specifics of the side effects in the progress note and a referral to contact the psychiatrist.

Instructed to Contact a Psychiatrist

This is checked when you make a referral to a psychiatrist for an initial evaluation, medication review, side effects, or medical noncompliance.

N/A

This is checked when the patient is not prescribed any medication.