We are required in triage to enter their meds....dose, route, & frequency. If they do not take any meds that must be documented as well. Our computer system stores this info. Then with any visit these meds automatically show up, & would have to be verified each time. The only problem is when whoever is in triage does not double check to be sure all of this is still correct......& just enters this old info as current.
If the pt is admitted we then have to hand write a med rec. with all the above, with time of last dose, pharmacy used, & if the med info was taken from pt bottles, pt/family recall, pt list, MAR from other facility. I always go in & go over each med with the pt/family to be sure they are correct....sometimes this is not possible if they can't communicate or have no family around.
The ER doctor then has to sign & check all meds as either continue or dc. If we could just print out the triage med rec it would save soooo much time!