1. Regional Medicine Prescription and Administration record Long Stay Kardex

2. Introduction
Welcome to this training module for the HSC Medicine Prescription and Administration Record 8 week kardex , commonly referred to as the ‘Long Stay Kardex’. This is a Kardex for acute adult patients and lasts for 8 weeks.

3. Learning objectives

4. Design

5. Differences to 2 week kardex
There are a number of differences to be aware of when using the long stay (8 week) kardex compared to the acute (2 week) kardex.
These will be covered in more detail on later slides.

6. Patient details This is the same for all regional kardexes
Use addressograph or write in capital letters for patient details.
Include ward, hospital and consultant.
Weight is recorded in kg and where relevant for medicines based on body surface area, the height is also recorded and BSA calculated.
The number of Kardexes in use should also be documented in the top right hand corner together with the date that a Kardex is rewritten.

7. Allergy Allergy box is standardised for all regional kardexes
Allergy status must be documented for all patients on admission. Where the patient has no known allergies this is documented by ticking the box as shown on the left, where the patient has an allergy the allergen and the nature of the reaction and the date of the reaction must be documented as shown on the right. The allergy documentation must be signed and dated by the person completing the record.

8. Risk factors / Additional charts
The risk factors section is the same as the 2 week kardex.
Risk factors that are relevant to prescribing of medicines are indicated by ticking the appropriate box(es) and signing and dating the entry.
The ‘Additional charts in Use’ section has been amended from the 2 week kardex to reflect the common charts expected to be used in long stay settings
Any other medicine charts in use must be referenced on the Kardex to ensure that any person reading the Kardex is aware of all medicines that the patient is prescribed.
The relevant tick box(es) must be ticked and a medicine entry made in the relevant section of the Kardex.
All additional A4 charts must also be tethered to the main kardex and kept together.

9. Abbreviations
The accepted abbreviations for route and frequency are printed.

10. Medicines Management
This section is to document Medicines Reconciliation, Medicines brought into hospital and how medicines are managed outside of hospital and on discharge.
Addition to 2 week kardex : frequency of dispensing – for patients who require supply of medication in instalments less than a month.

11. Codes for recording omitted doses
The codes for recording omitted doses are used when a medicine dose is intentionally omitted or delayed.
The nurse enters the reason using the codes shown from 1-7 and a circle placed around the relevant number in the administration record. If there is an ‘other’ reason that does not fit with a pre-printed code, then ‘7’ is entered and details of that other reason are documented on Page 9.
Where a prescriber intends for a dose to be withheld, the prescriber enters code ‘8’ on the administration record for each dose that they intend to be withheld and places a circle around the number and enters further details in the additional notes section on Page 1 or in medical notes.
Only a prescriber can use code ‘8’. Where a nurse omits a dose on the separate instruction of a prescriber they enter code ‘7’ and document details of this instruction on Page 9.
Examples of the codes in use will be provided in later slides.
Compared to the 2 week acute kardex an additional code has been added to the list – code 9 ‘Patient asleep’.

12. Additional notes on medicines
This section is used to document key information relating to medicines such as medicines that have been stopped or temporarily withheld.
A space for a patient photograph has been added – this is optional and is as per local policy

13. Venous Thromboembolism Risk Assessment
All patients must be assessed for risk of venous thromboembolism (VTE) on admission, reassessed within 24 hours and whenever clinical condition changes.
The VTE risk assessment in the long stay kardex allows reassessment of the VTE risk to be recorded.

14. Oxygen
Oxygen is prescribed here as required by National Patient Safety Agency recommendations and British Thoracic Society guidelines.
The prescriber indicates if the patient is a ‘known CO2 retainer’. Initial flow rate, device and target oxygen saturation are prescribed as shown.
The nurse, following the initial prescription by the prescriber, must sign for the oxygen therapy on each medicine round and record the device and flow rate used to achieve the target saturation. The device and flow rate are recorded using the abbreviations listed below the oxygen prescription.
NB. The initial prescription does NOT need to be rewritten if the device or flow rate is changed by the nurse or physiotherapist who must document the change in clinical notes. Remember, rapid changes in clinical condition require medical review.

15. Oxygen
Oxygen is prescribed here as required by National Patient Safety Agency recommendations and British Thoracic Society guidelines.
The prescriber indicates if the patient is a ‘known CO2 retainer’. Initial flow rate, device and target oxygen saturation are prescribed as shown.
The nurse, following the initial prescription by the prescriber, must sign for the oxygen therapy on each medicine round and record the device and flow rate used to achieve the target saturation. The device and flow rate are recorded using the abbreviations listed below the oxygen prescription.
NB. The initial prescription does NOT need to be rewritten if the device or flow rate is changed by the nurse or physiotherapist who must document the change in clinical notes. Remember, rapid changes in clinical condition require medical review.

16. VTE Prophylaxis NB : Difference to acute (2 week) kardex :
The first entry in the section does not have ‘enoxaparin’ pre-printed – there is a prompt to consider VTE prophylaxis or treatment as appropriate following VTE risk assessment on each page.

17. Regular Medication
The long stay kardex does not have separate sections for prescription of injectable and non-injectable medication.
All regular medication irrespective of route of administration is prescribed in the one section.
Administration can last up to 8 weeks if needed.

18. Regular medicines Prescription and administration
The prescriber should specify the:
Name of medicine in capital letters
Start date
Dose / Route (using abbreviations) / Frequency (using abbreviations)
Special instructions/indication
Medicines Reconciliation
Signature of prescriber (include Professional Number and Print name on one entry on the Kardex to ensure the prescriber can be identified)
The circled times of administration
The administration record should be completed by signing the box that corresponds to the date and time that the dose is due. Administration can last up to 8 weeks and signatures continue across the double page.

19. Regular medicines- Other times
Where a medicine is required to be administered at a time other than the pre-printed administration times, the prescriber writes in the time in the adjacent column and circles the time as shown.

20. Prescription and administration Withholding a dose
The prescriber should specify the:
Name of medicine in capital letters
Start date
Dose
Route (using abbreviations)
Frequency (using abbreviations)
Special instructions/indication
Medicines Reconciliation – this is particularly helpful for those completing the discharge prescription to enable changes to medication during admission to be highlighted.
Signature of prescriber (include Professional Number and Print name on one entry on the Kardex to ensure the prescriber can be identified)
The circled times of administration. Where the required time of administration is different to the pre-printed times, this time should be written in and circled as shown.
The example shown also illustrates where the prescriber has annotated the administration record to withhold ramipril for 48 hours post-operatively by inserting ‘8’ in the administration record. Alternatively, where a medicine is to be withheld for a longer time the prescriber can discontinue the prescription and add a note in the additional notes section on page 1 to advise that the medicine has been withheld and the reason why.
The nurse completes the administration record by signing the box that corresponds to the date and time that the dose of the medicine is due.

21. Omitted and delayed doses
Enter the relevant code in the administration record when a dose is intentionally omitted or delayed.
The example shows that the morning doses of medicines were omitted because the patient was vomiting and then administered 2 hours later and documented as shown.
It also illustrates where furosemide was omitted due to hyponatraemia with the further detail of this omission documented on Page 9.

22. Regular Medicines Less than once a day
Some medicines are prescribed less than once a day in which case the prescriber should draw a box around the day(s) of the week when the dose is due to be administered and a line through the remaining boxes.

23. Regular Medicines Once a week
A further example of this is shown with oral methotrexate where the day of the week should also be written in the Special instructions/indication box.

24. Regular Medicines Variable Dose

25. Discontinuing/Changing a prescription
Where a prescription is to be discontinued, a diagonal line should be drawn through the prescription section, a zigzag line drawn through the remainder of the administration section and the stop box dated and signed.
Where a change is required to an existing prescription for example dose or frequency, no amendments should be made. Instead the original prescription should be discontinued as above and a new prescription written for the changed dose or frequency. In the example shown, a patient was admitted on simvastatin 40mg which was reduced to 20mg.

26. Additional charts
Any additional charts in use must be referenced on the Kardex by using a prescription section as shown. Details of the dose are on the additional chart and not on the Kardex.

27. Omitted doses of medicines coded ‘7’ and delayed doses
Where a medicine dose has been omitted for an ‘other’ reason or delayed, further information is recorded in this section.

28. As required medicines
Within this section, more than one route can be prescribed within a single prescription provided the dose is the same for different routes as shown with cyclizine. Where the dose is not the same for different routes, two separate prescription must be written. This section also includes the maximum dose in 24 hours.
The indication can be stated where appropriate.
14 doses can be administered against an as required prescription after which it must rewritten for further doses to be administered.
The administration record is completed by filling in immediately to the right of the dose previously administered, confirming that the minimum dose interval has elapsed.

29. As required medicines

30. Once only medicines pre-medications / medicines administered under PGD
This section is used to prescribe once only medicines and pre-medications.
When prescribing these, they must also be communicated to nursing staff to enable timely administration.
Where a medicine is administered under a Patient Group Direction (PGD) the entry is documented within this section but instead of a prescriber’s signature, the nurse enters ‘PGD’ in the column for the prescriber’s signature as shown.

31. Regular Long Acting Injections
This section is unique to the long stay kardex and allow prescription of long acting injections in a separate section to the rest of the kardex.

32. Summary
It is hoped that this module has been helpful to you in explaining how to use the Kardex. If you have any further questions you can contact the Medicines Governance Pharmacist or education facilitators in your trust.