Medication Reconciliation Education


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  • Admission as inpatientTransfer in and out of ICU or ORDischarge: home or to other facility
  • RN’s job is to take history from the patient/caregiverto create an accurate home med listAfter history has been taken, pharmacy will see what has been ordered and then do the RECONCILIATON between home meds and ordered meds to make sure our patients are getting the correct medications!!Exceptions for starting this process…SNF/CBRF patients: provide MAR to pharmacy by making a copy of original for themEMA: early morning admissions and surgicals interviewed by pharmacist in SPC but other medical patients should be done by RNCPU: nurse or physicianER: minimal expectation is verifying NAMES ONLY- additional info may be obtained and added If pharmacy has started do not change anything – just call pharmacy. We will see in later screen shots how to tell if pharmacy has started.
  • Here is where we talk about if a pharmacist has already begun…if you get to med rec and pharmacy has already begun, the status menu will be filled out already with an RPh statusIf one of the highlighted choices is selected, please…do not change anything in the list…and do not change the status – call pharmacy with any changesThis alters our reporting for med reconciliation for meaningful use numbers!!
  • Examples:Name =metoprololDose= 25 mg, one etc.Dose form = tablet, liquid etc.Route = by mouthFrequency = dailyDate/time of last dose = am/pm or actual timeAnother example…multivitaminMultivitamin needs to have “one” as dose…for an incomplete order complete order it would read:Multivitamin one tablet by mouth daily
  • Still need to add dates and times of last doses
  • This makes everyones job easier, placing it in the text box it is kept with this admission instead of forever.
  • click#1: For each med:Review name, dose, route, frequency for accuracy of what pt is doing at homeclick#2: also for each med: add date and time of last dose and any other information to share with*** here is where you would use the red X to delete medications that don’t need to be on the list. If you need to delete a medication and then re-add it as necessary to make this list correct.When you have finished the list…click#3: pick your status…click inpatient RNs pick from: RN: unable to obtain, RN:incomplete or RN:completeclick ER RNs pick from: ED: unable to obtain, ED:incomplete or ED:completeclick#4 add a reviewer note… clicking on the “add note” link brings up a pop up boxclickuse the smart phraseclick#5 click on mark as reviewed – this is how you get credit for all of the work you just did and how it saves the changes you made in the history section.clickwhen you do that, your name will appear as the person who last reviewed the information. clickHistory – able to pull up history of who did what with the med rec…used mostly by pharmacy and QI auditors
  • If pt is OOU and held in ICU because there are no beds and then declines, must then med rec again…if again made ICU patient.
  • Show facility transfer order report:Patient summary – report (wrench)- facility
  • Print 2 copies – one for chart, one for facility
  • Medication Reconciliation Education

    1. 1. MedicationReconciliation Education April 2013
    2. 2. Medication Reconciliation EducationPurpose: We can improve patient safety and careoutcomes by performing medication reconciliation  Everyone plays a role in Medication Reconciliation  Our medication reconciliation policy has been simplified  Audits have shown that Medication Reconciliation done by nurses are sometimes incomplete  This is your education about the new policy changes
    3. 3. Medication Reconciliation Our policy is organized in 3 ways:1. Patient Status • ED vs. Inpatient/Observation2. The action occurring with the patient a) Admission b) Transfer c) Discharge3. Role of person engaged in Med Reconciliation a) Nursing responsibilities b) Pharmacy responsibilities c) Prescriber responsibilitiesNote: For this education, we are focused on Nursing responsibilities only
    4. 4. Medication Reconciliation When do we need to reconcile medications?  Admission  Transfer  Discharge
    5. 5. Medication Reconciliation Exceptions to completing the regular process:  ED: review names only  Cardiac Cath/EP lab: med report from field  Interventional radiology: provide pharmacy list of meds, allergies and contrast medication orders  Daycare patients for procedures (with no med adjustment): med names and allergies  Peds sedation: Med names and allergies  Dialysis – dialysis meds are not included on home med list
    6. 6. Medication Reconciliation ED (preadmission)  Review names of meds only  Record dates and times of last doses for antibiotics and b-blockers  Record any other med information related to care in the ED in the text box for last dose  If there is a med that has been completed you may remove by using the red X  In the text box for Last dose:  Type“Y” if pt is taking the medications  Type “N” if pt is not taking the medications  When review is complete fill in status box  Mark as reviewed
    7. 7. Beta-blocker or Antibiotic here Date and time here Select one of these 3 “y” or “n” in this options text box
    8. 8. Medication Reconciliation Admission – Nurse responsibilities Goal: Obtain medication history to create an accurate home med list Exceptions for starting this process… 1. Certain patient populations:  SNF and CBRF patients- give a copy of MAR to pharmacy  SPC – pharmacy interviews surgicals and medical EMAs, RN interviews the other medical patients  ER only verified names of meds, admitting RN needs to complete 2. Pharmacy has already completed the med history or reconciliation (see next slide)
    9. 9. If pharmacy has chosen astatus before you begin…call the pharmacist prior tochanging the list or thestatus box
    10. 10. Reviewing Medications Information to include with each med:  Name Metoprolol Multivitamin  Dose 25 mg One  Dose form Tablet Tablet  Route By mouth By mouth  Frequency Daily daily  Date/time 2/28/13 0800 2/28/13 am of last dose - am/pm is ok most of the time  Beta blockers, Antibiotics need specific time  Ask about OTCs, herbals, eye drops, nasal sprays etc
    11. 11. Adding MedicationsAdd the missing medication, include the same elements as in the review and document date and time of last dose Add date and time of last dose Add all medication information
    12. 12. Removing MedicationsRemove meds that the patient is appropriately nottaking by using the red X and selecting “removefrom PTA list”examples: completed antibiotics completed surgical prep MD instructed pt to d/c use Duplicate entries of the same med
    13. 13. Changing Medications  ifpatient is taking med differently than listed but according to MD instruction  remove med entry using red X  add med as above
    14. 14. Unclear Entries If it is unclear if the medication should be removed from the list or changed, just type the information into the last dose field for the pharmacist to review. When might this happen?  Non-compliant patient  Patient changed dose or frequency without MD knowledge  Patient misunderstood directions and has been taking incorrectly  Pt stopped med for financial reasons  Patient can only provide a portion of the information
    15. 15. Please use last dose field for communication…not the paper icon Writing in the paper icon stays in the chart forever so just pretend it isn’t even there!HappyPharmacist Unhappy Pharmacist
    16. 16. Inpatient RN
    17. 17. Medication Reconciliation Transfer of patient – Nurse responsibilities  Release orders at the time of pt physically transferring to the new unit  If pt unable to be physically transferred, release and act on the orders – the orders are considered a level of care change regardless of physical location
    18. 18. Medication Reconciliation Discharge – Nurse responsibilities  Review the orders and check the status of d/c orders in shopping cart  Provide patient necessary discharge documentation, medication education and d/c instructions  d/c to another provider: print facility transfer order report (2 copies – one for facility and one for SMH chart)
    19. 19. Facility Transfer Orders – for discharge