Medication Management – Systems Interface Review

Instruction:

  1. For active patients selected by the surveyor, complete the chart below noting the patient’s name and MR number, diagnosis whether or not medication allergies were identified and if so, the specific allergies. 2. For each patient review the patient charts and select three high-risk drugs per patient to review. In selecting your high risk drugs consider: Medication for pain mgmt; antibiotics; anticoagulants; other high-risk meds (insulin). 3. On the form note the data from the various med systems in your organization (at a minimum those identified above, e.g., orders, MAR, pharmacy profile, etc.) which track the mgmt of the medications for the patient for three specific days: day of admission, 2 days post admission and the current day. Highlight any discrepancies, missing information. 4. On the form highlight any discrepancies between your data sources/system’s information for the selected medications. 5. Provide the completed form to the surveyor at the time specified but no later that noon on day two of a two-day survey.

  1. Patient Name/ID
  2. Date of Admission
  3. Locations
/
  1. Diagnosis
  2. Med Allergy List
  3. Indication for Med
/
  1. Orders
  2. Note if this includes change of order or change in patient location;
  3. Note any order, discrepancies, e.g., inconsistent unacceptable abbreviations, transcription errors, dosing delays, etc.
/
  1. MAR (Verify drug, dose, route, frequency, timeliness)
  2. Verify that the doses administered were consistent with the order; within dosing range; note any Pharmacy/Nursing MAR reconciliations
/
  1. Pharmacy Patient Profile
/
  1. Pharmacy review for drug appropriateness (indication for rationale for drug)
/
  1. Medication Monitoring
  2. Pain assessment
  3. Labs: ordered; completed; available timely manner
  4. Changes in patient condition, WBC,  Temp, etc.
/
  1. Other Systems or documentation source regarding medication management (e.g., nursing notes, incident reports, etc.)

Example

J. Doe
2222222222
DOA 1/1/2003
ER admit to Ortho / Fx tibia
Sulva allergy noted in H&P, Nursing Assessment / 01-01-03 @ 1100 MS-PCA 4 mg q 10 mi9n 20 mg q4hr lockout / Same as order
9.8 @ 1200
6.4 @ 1300
4.0 @ 1800 / Sulfa allergy not noted in Pharmacy profile / Rationale and medication appropriate / No Pain score @ 1200
No pain score @ 1300
Pain score 6 @ 1800 / Pt education by RN on proper use PCA and demonstrated understanding
01-02-2003 @ 1040
PCA dc’d MS 4 mg IVv q 2-4 hr prn severe pain / 1.9 @ 1000 / Same / OK / No pain score / 1745 nsg not pt c/o of pain – no note of meds given

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Instruction:

  1. For active patients selected by the surveyor, complete the chart below noting the patient’s name and MR number, diagnosis whether or not medication allergies were identified and if so, the specific allergies. 2. For each patient review the patient charts and select three high-risk drugs per patient to review. In selecting your high risk drugs consider: Medication for pain mgmt; antibiotics; anticoagulants; other high-risk meds (insulin). 3. On the form note the data from the various med systems in your organization (at a minimum those identified above, e.g., orders, MAR, pharmacy profile, etc.) which track the mgmt of the medications for the patient for three specific days: day of admission, 2 days post admission and the current day. Highlight any discrepancies, missing information. 4. On the form highlight any discrepancies between your data sources/system’s information for the selected medications. 5. Provide the completed form to the surveyor at the time specified but no later that noon on day two of a two-day survey.

  1. Patient Name/ID
  2. Date of Admission
  3. Locations
/
  1. Diagnosis
  2. Med Allergy List
  3. Indication for Med
/
  1. Orders
  2. Note if this includes change of order or change in patient location;
  3. Note any order, discrepancies, e.g., inconsistent unacceptable abbreviations, transcription errors, dosing delays, etc.
/
  1. MAR (Verify drug, dose, route, frequency, timeliness)
  2. Verify that the doses administered were consistent with the order; within dosing range; note any Pharmacy/Nursing MAR reconciliations
/
  1. Pharmacy Patient Profile
/
  1. Pharmacy review for drug appropriateness (indication for rationale for drug)
/
  1. Medication Monitoring
  2. Pain assessment
  3. Labs: ordered; completed; available timely manner
  4. Changes in patient condition, WBC,  Temp, etc.
/
  1. Other Systems or documentation source regarding medication management (e.g., nursing notes, incident reports, etc.)

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