Who is responsible for entering home medications and drug allergies into a patient's chart?

In a clinical setting, the responsibility of entering home medications and drug allergies into a patient's chart typically falls to the medical assistant. Medical assistants often perform administrative and clinical tasks, including documenting patient information and maintaining accurate medical records. Their role includes gathering comprehensive histories that encompass current medications and any known allergies, which are critical for safe and effective patient care.

The accurate recording of this information is vital as it aids healthcare providers in making informed decisions regarding treatment and medication management. This process often happens during the patient's intake or prior to their examination.

While other healthcare professionals, such as registered nurses, physician assistants, and pharmacists, may also engage in aspects of medication management and may verify or review this information, the medical assistant is generally tasked with the initial entry into the patient's electronic health record during visits.