Medication History: Keeping our patients safe. How do we get all of the correct details?

Medication History Process - Basics Medication History is the foundation for the: - Safe c are and management of patients - Medication reconciliation process Medication History has been documented in the Kaleida Health electronic medical record (KH EMR) for all patients since February, Complete Medication History requires accurate documentation of each medication with dose, route, frequency, indication, compliance and last dose.

Medication History Process - Background Documentation of the Medication History is ONE step in the complex process of Medication Reconciliation. Physician orders and medication reconciliation will remain on paper until 2012 EMR medication history documentation was assessed: -Improved forms will be implemented when technical development is completed. -This presentation will focus on the need for safe and complete nursing documentation of medication history at both initial and return visits.

Medication History Process - Conclusion Nursing is responsible for the documentation of medication history including: All prescription details (medication, dose, frequency, route, indication, compliance and last dose). Collecting information from a variety of sources (patient, family, pharmacies, providers). Documenting additional information presented during the course of the patient’s stay. Update at each encounter, validating every medication and confirming each detail.

Steps in the Process – How to Interview? At EVERY KH Encounter - The patient must be interviewed by a nurse to obtain the MOST accurate medication history for documentation in the KH EMR. How ? Lead the conversation! Examples: “Is this medication what the provider prescribed for you?” “I see your medication list is in your patient chart. To make sure everything is accurate and up to date let’s start at the top of the list and go over each medication with details.” “Do you have a list of medications that we can go over together?” “Do you have anyone we can call for your medication list?”

Steps in the Process – What to Document ? In addition to the medication name, five (5) elements are REQUIRED by policy: Dose Route Frequency Indication Compliance – Status – Source – Date and Time of last dose

Steps in the Process – When to Document ? At every point of entry - new visit or returning visit: – ED visit – Direct admission, Admission – Same Day Surgery, procedures – PAT You are collecting medication history like it is the first time, EVERY time!

Steps in the Process – When to Document ? Updates must be made throughout the patient’s hospitalization. If a new medication is discovered or a clarification is made to a listed medication, the nurse must update the medication history in the EMR. The nurse is responsible for notifying the provider to determine if the medication should be ordered for the inpatient stay. When an update is made a new Discharge Medication Information sheet must be printed to replace the old one in the chart.

Patient Scenarios Scenario 1 – Direct Admit Patient - Discovered Meds Scenario 2 – The Returning Patient Scenario 3 - The Discharged Patient Scenario 4 – ‘Unable to Obtain’

Scenario 1: Direct Admit Patient A direct admit patient arrives to the inpatient unit with no medication history documented in the EMR. The nurse interviews the patient and enters the list of home medications into the EMR. The Medication Information and Order form is printed. The Admission order box is checked as appropriate based on admission orders. New orders are placed on an Order Forms and both forms are scanned to the pharmacy. These forms are not changed after scan to pharmacy. The patient’s family arrives with a home medication list, including additional medications. The patient’s physician prescribed Lasix 40mg daily. The family reports that the patient takes 20mg to save money. The nurse handwrites the additional medications on the Addendum/Downtime Form. The provider is contacted to determine whether added home meds should be ordered for the inpatient stay. The Addendum Form is scanned to pharmacy. The EMR Medication History is updated. The use of Lasix is documented using the Compliance section, selecting ‘not taking as prescribed’ and adding a comment. A new Discharge Information form is printed, replacing the old form in the chart.

Scenario 1: Lessons Learned Once a Medication Information and Order form is scanned to pharmacy, NO changes are made to the order form. If additional medications and/or clarifications are discovered during the inpatient stay: -RN handwrites all five elements on the Addendum/Downtime Form. - RN notifies the provider who determines if medications should be ordered for the inpatient stay:  Check ‘YES’ on order form and scan to pharmacy  Check ‘NO’ on order sheet and scan to pharmacy - The form is placed in the BACK of the orders section of the chart Home Medications are documented with details as prescribed. Actual compliance is reported in the Compliance section. Any free text documented in Special Instructions, Order Comments or Compliance Comments will display on the printed form.

Scenario 2 – Returning Patient A patient arrives in the ED with a previously documented medication history, including an antibiotic. The nurse will: Interview the patient to confirm each medication, with all details. The antibiotic is cancelled, selecting ‘treatment complete’ as the reason. The Medication Information and Order form is printed. Call the provider for orders. He reports that Toprol was changed last week to 25mg and he orders Lasix 40mg IV daily to replace Lasix 20mg PO daily. Handwrite the Toprol change to 25mg on the Medication Information form and check ‘Yes’. Check ‘No’ to indicate that the Lasix 20 mg is not ordered for the inpatient stay. Use an order form for the Lasix IV. The Medication Information and order forms are scanned to pharmacy. The nurse updates the Toprol dosage in the EMR medication history and prints an update Discharge Medication form.

Scenario 2 – Lessons Learned All medications that a patient is no longer taking should be discontinued in the KH EMR. This would include: – Antibiotics whose prescribed course is completed – Any medications that a patient is no longer taking Completed prescriptions must be canceled from Document Medication by History section of the EMR.

Scenario 2 – Lesson Learned Note the cancel selection Documenting Completed Medication

Scenario 3 – Discharging the Patient What if home medications are changed at the time of discharge? The physician will use the Discharge Information form to select which home medication will be continued at home. All NEW home medications are handwritten on the Discharge Medication Information. Changes in home medications at the time of discharge are NOT reentered into the EMR. This step will be implemented with CPOE (Computerized Physician Order Entry).

Scenario 4 – Unable to Obtain An unresponsive patient comes in to a Kaleida Facility without family or information sources. The patient has a previous medication history documented. Therefore, the “Unable to Obtain button is dithered. The nurse will Cancel all existing Home Medication History entries using the following steps: Click the tab Highlight all the entered medications. Right-click “Cancel/DC”

Scenario 4 – Unable to Obtain Select ‘Unable to Obtain’ as the appropriate Discontinue Reason Click button When the patient, family, provider and/or Pharmacy can provide the Home Medication History, it should be entered according to standard procedure.

Scenario 4 – Lessons Learned All medications can be viewed using the ‘All Medications, All Status’ after meds are cancelled. Select ‘All Med’ status to view cancelled meds

Medication History Position Statement Accurate documentation of Medication History helps to ensure the safety of our patients. As of February 2010, medication history is recorded and stored in the electronic medical record (EMR) for all Kaleida Health patients. Information on the patient’s medication history serves a reference in the care and management of patients and it is the foundation of the medication reconciliation process. It is the responsibility of KH nursing staff to document medication history in the EMR, ensuring that it accurately reflects all prescription details (medication, dose, frequency, route, compliance and last administration) utilizing a variety of information sources (patient, family, pharmacies, providers). If additional information is presented during the course of the patient’s stay regarding the patient’s home medications prior to admission then the patient‘s history will be updated in the EMR. Nursing staff will update medication history at each new encounter with a Kaleida facility. This review and update will cover each medication, including all details.