Document Sample
    2009 JCAHO directive that
 medication reconciliation be done
on admission, transfer, discharge &
         be documented
         Admission Med Rec
• Admission Med Rec Form must be used for
  ALL patients.
• If no home meds, write “none” (or check
  box) and send yellow copy to pharmacy.
• Include ALL meds - prescription, OTC,
  herbals, breathing treatments (respiratory tx
  must be written on physician order sheet -
  or Respiratory will not be notified)
         Admission Med Rec
• Make sure to fill in ROUTE & Date/Time
• Pharmacy will print MAR after medication
  reconciliation is complete.
• Current audit - Med Rec on chart 100%.
• Filled in correctly - 88% - (missing route &
  last dose).
       Admission Medication
       Reconciliation Forms

• Inpatient Medication Reconciliation Form
• Outpatient Medication Reconciliation Form
• Either acceptable for inpatients.
     Admit Med Rec Includes:

• Obtaining list of home medications
• Reviewing and ordering medications
  patients may have received in other
  departments at BRMC before coming to
  your unit - especially ED meds.
              Question #1
• Patient admitted from ED, admission med
  rec filled out. Receiving nurse has to:
• A. Call attending physician and get home
  meds renewed.
• B. Tell attending physician what meds
  given in ED, so they can be ordered or not.
• C. Both A & B.

• C. Both.
• Home meds must be reviewed and
• Meds started in ED may need to be ordered
  (like nitro or antibiotics).
         Discharge Med Rec
• Physician must give nurse a list of
  medication the patient is to go home on.
• If this does not occur, Nurse must CALL
  physician to obtain list (or it looks like
  nurse is prescribing without a license).
• Physician must check & sign TMO, or
  write out list on physician order sheet, or
  fill in discharge meds on dc form.
        How to Print a TMO
• Find “CERNER” in the “NOVELLE
  applications” box on the bottom of screen.
• Double click on “CERNER” application.
• Sign in with your “U#”
• Password - call help desk to reset 1st time
• On bottom - type in “BTMO”, then “enter”
• Type in next to printer your printer #.
                Print TMO
• After typing in “BP#” for printer, hit “enter”
  3 times.
• Type in patient’s financial #; hit “enter”
• Hit “Y” if information correct.
• Report will print on your printer.
• Printer # & instructions on BRMC home
  page under “communications” “TMO/OMI”
               Question #2
• In order to print a TMO, the nurse will
  probably have to:
• A. Call the help desk the first time to get
  password reset.
• B. Disregard the top of the 1st screen and
  type in BTMO (for Bay TMO).
• C. Both A & B.
                Answer #2
• C. Both A & B.
• The password has to be re-set if not used in
  the last 3 months.
          Discharge Med Rec
• All meds from admission med rec need to
  be reviewed at discharge, in order to
  reconcile admission meds & current meds
  to come up with discharge med list!
• Blanket orders are not acceptable- ie: “meds
  as at home” - call and get a list.
• After nurse has list from physician, nurse
  transcribes list on to patient discharge form.
• Nurses CANNOT write prescriptions -
  physician must sign it!
• Nurses can call prescriptions to pharmacy if
  there is a WRITTEN order (even phone
  order) on physician order sheet, which
  includes # of tabs to dispense.
• Physician will sign in HIS after discharge
  (which covers nurse not prescribing).
      Discharge Instruction Form
•   To meet Core Measures, use the right form!
•   General Discharge Form (NS-1410)
•   Cardiac Discharge Form (NS-9034
•   Cardiac Surgery Discharge Form (NS-9007)
•   Stroke or TIA - Stroke Discharge Form
              Question #3
• Patient is on 3 West, was previously on
  4West and was admitted with Heart Failure.
  For the discharge form, use:
• A. General Discharge
• B. Cardiac Discharge
• C. Stroke Discharge
               Answer #3
• B. Cardiac Discharge form is used to meet
  Core Measures regarding medication and
  smoking cessation.
    Discharge Med Rec Process
• Compare the TMO to the admission med
  rec or “home meds” listed on the TMO.
• Have all medication been addressed?
  Change is OK.
• Fill in on discharge form “Stop taking these
  meds” for medications that have been
         Filling out the Form
• Fill out form completely
• If med list comes from prescriptions, check
  box “prescriptions” (coming on new forms).
• Draw line thru items that are not applicable.
• Fill in “vaccine” information - give
  influenza or pneumonia shot @ discharge
  for EVERY eligible patient!
         Filling out the form
• Utilize “X” in box under “breakfast, lunch,
  dinner, or bedtime” columns, instead of
  writing “three times a day”.
• These columns help patients figure out what
  medications they have had already and what
  they need to take after they get home.
• They will adjust their med schedule around
  their home schedule.
      Purpose (third) Column
• Patients need to know what the drug does -
  what it is for - providing this information
  helps them learn.
• Just use 1 word - what system does the drug
  affect?(Click here for examples).
• Example: antibiotic, pain med, Pepcid-
  stomach, Coreg - heart, Norvasc - BP, etc.
        “Ding” from JCAHO
• When JCAHO reviewed discharge form,
  they found mistakes in transcription - a
  medication was missed.
• When 70 charts were reviewed, 9 errors
  were found in transcription - meds missing
  or meds included that were discontinued.
• Please be careful - double check your list.
            Avoiding errors
• It was easy to see when a nurse had been
  interrupted while transcribing the list -
  suggestion - take the chart in the patients
  room (and hide) - tell the patient what you
  are doing, and have them participate in the
• Patients appreciate the input, and appreciate
  how much work this is for you!
• Physician responsible to provide list
• Nurse responsible to transcribe and give list
  to patient.
• LPN may transcribe list, but needs RN to
  sign discharge form BEFORE giving list to
               Question #4
• Patient is discharged, but physician has left
  no list of medications to put on discharge
  form. Nurse will have to:
• A. Call physician and review TMO,
  addressing home meds that were dc.
• B. Just copy the TMO or Admission Med
  Reconciliation onto the discharge form.
               Answer #4
• A. Call the physician and read the list of
  medications on the TMO, making sure to
  address the previously discontinued home
  medications on the last page.
       More Responsibilities
• Patients who leave 1900 Columbus Avenue
  to go ANYWHERE have to have a list of
  their medications given to:
• the next care provider (institution or
• & the patient (or family if patient not
             Going to ECF
• Complete “Inter Agency Transfer Form”
  SS-2216 and SS-2216A (2 pages).
• Complete Discharge form.
• Send copy of TMO to next institution
• Give copy of TMO to pt or family, or fill in
  meds on discharge form.
      Going to Mental Health
• Complete discharge form, with medication
• Call report to MH
• Do NOT need to send TMO or Inter
  Agency Referral Form.
Going to Foster Care or Assisted
• Complete discharge form with medications
• Do NOT need interagency Referral Form
• Do NOT need to send TMO.
• Send patient with discharge form, filled out
  as much as possible - may write “follow
  instructions after discharge from BSCC”.
  (trying to capture Core Measures here).
• Send TMO to institution & Call Report
• May give TMO to pt/family instead of
  writing meds on discharge form.
• No Inter Agency Transfer Form
         Next Care Provider
• Physicians have access to the patient’s
  discharge medication list through their
  access to the Electronic Medical Record.
              Question #5
• Patient was admitted to 6E with CVA,
  going to Inpatient Rehab. Nurse sends:
• A. Stroke discharge form -with meds filled
  in or a copy of the TMO given to pt/family
• B. MAR & chart
• C. Transfer form
• D. A & B
                Answer #5
• D. Give patient/family Stroke Discharge
  instructions, either filling in the meds the
  patient is currently on or giving pt/family
  copy of TMO.
• AND send MAR and chart to Rehab with
   The NEXT Phase - Transfer
• JCAHO Regulation #8.02.01 for 2009 says:
• The pt’s most current reconciled medication
  list is communicated to the next provider of
  service, either WITHIN or outside the
• The communication between providers is
• Don’t think of “transfer” - think “patient is
  discharged from my area (floor) and
  admitted to a new areas (floor)”.
• This is an opportunity to stop medications
  that are no longer appropriate or necessary,
  or restart medications that were stopped.
• Patient is “discharged” from Critical Care
  and “admitted” to any other floor.
• Patient goes from 6th floor to Telemetry.
• Patient goes from Telemetry to 6th or 3rd.
• Patient goes to Critical Care.
• Patient goes from OR to any other floor
  (even if they go back to the bed they left).
           More Examples
• Inpatient goes to cath lab/CVCU to 4th or
  5th floor.
• Procedural Areas - Endoscopy, Radiology,
  these are gray areas now - more to come.
• Nursing should be aware of medications pt
  received during procedure & med
  interactions (pain meds, metformin must
  be held for 48° after ANY contrast dye).
• Administration Policy #218 “Medication
  Reconciliation” by P & T Committee.
• “Physician must review meds on transfer”
• Physician can use TMO or write list, just
  like discharge.
• If physician does not address meds,
  RECEIVING Nurse calls & reviews TMO.
             Phone Orders
• Remember to “read back” phone orders to
• Remember to use “sign here” stickers for all
  phone orders for physicians to sign.
• Use “P.O.” for phone orders, not V. O.
  (verbal order).
        More Documentation
• This active review process must be
  documented by the receiving nurse, even if
  no changes are made.
• Check box on TMO or Admission Med Rec
  Form “medications reviewed”.
               Question 6
• Patient was sent from Critical Care to 3
  East, the receiving RN must:
• A. Call the physician and review the TMO,
  since no medications were addressed in the
  transfer order.
• B. Do nothing.
• C. Ask the Pharmacist what meds to give.
               Answer #6
• A. Call the physician and review the TMO,
  checking the line of medications the
  physician wants to continue, and signing the
  bottom “p.o. Dr. X/N. Nurse, RN.
                  The End
• Thank you for completing Medication
• Please click here and PRINT the
  Certificate on the next screen, fill it in
  and give it to your manager.