MEDICATION RECONCILIATION 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 of LAST DOSE. • 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. Answer • 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. Prescriptions • 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 (NS-1185) 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 discontinued. 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 process. • Patients appreciate the input, and appreciate how much work this is for you! Responsibilities • 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 patient. 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 physician) • & the patient (or family if patient not competent). 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 list. • Call report to MH • Do NOT need to send TMO or Inter Agency Referral Form. Going to Foster Care or Assisted Living • Complete discharge form with medications listed. • Do NOT need interagency Referral Form • Do NOT need to send TMO. BSCC or BRMC REHAB • 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 patient. 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 hospital. • The communication between providers is documented. “Within” • 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. Examples • 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). Responsibilites • 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 physician. • 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 Reconciliation. • Please click here and PRINT the Certificate on the next screen, fill it in and give it to your manager.