chapter 23 medication records in the nursing homefile.cop.ufl.edu/ce/consultwb/2010workbook/chapter...
TRANSCRIPT
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23.1 1
CHAPTER 23
MEDICATION RECORDS
IN THE NURSING HOME
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23.2 2
NURSING HOME
Medication Records in the Nursing Home
1. MAR’s, TAR’s & PRN Sheets
2. Monthly Summaries (Recaps or Physician Order Sheets)
3. Who produces these documents?
4. How are med sheets kept current?
5. How does the Pharmacy get notified of order changes?
6. The month-end process used to review new med sheets
7 Who is responsible for the accuracy of new med sheets?
8. How to avoid the biggest opportunity for med errors and omissions
9. The Importance of the position of med orders on the Med Sheets
(1) PRN’s first or last
(2) Organizing Ancillary Orders
(3) D.N.R. Orders or Living Will Statements
10. What happens to medical records after the end of the month?
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23.3 3
NURSING HOME
The Consultant Pharmacist should be looking for the following issues when
they review the MAR, TAR and PRN documentation.
The administration times for each medication in use
Does the daily number of doses administered match the written order (Ex written order is for TID but doses are being charted at 8am & 8pm)
Identify all medications that have been discontinued since the first of the month
Do nurses use a standard process to document discontinued medications
Are all changes in an existing order documented as a new order (Ex. If a dose goes from TID to BID has the nurse dc’ed the TID order and written a new order
for BID?)
Identify all new medications started since the first of the month
Have all new orders written during the past month been documented on the MAR
Doses of medication held and the reason they were held
Do nurses use a standard process to document “held doses” and has the prescriber been notified
Charting omissions that may compromise the effectiveness of the therapy
The use of PRN doses for the patient and the effectiveness of each dose
Do nurses use a standard process to identify administered PRN orders that need additional documentation (ex the effectiveness of the dose)
Doses that are being crushed or administered through a tube. Is it acceptable that these medications are being crushed? Is there a liquid alternative?
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23.4 4
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23.5 5
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23.6 6
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23.7 7
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23.8 8
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23.9 9
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23.10 10
NURSING HOME
ELECTRONIC MEDICATION RECORD COMPANIES (eMAR)
Artromick eMAR
www.artromick.com
(800) 848-6462
Creative Strategies (Accuflo –formerly eMedPass)
www.creativetrategies.com
(888) 339-7050
Daverci solutions
www.daverci.com
(503) 726-1420
Integrated Informatics
www.ii-i.com
(770) 643-6755 ext 227
MED e-care
www.mede-care.com
Toronto Ontario
(416) 686-8592
QuickMar
www.quickmar.com
(888) 340-9866
http://www.artromick.com/http://www.creativetrategies.com/http://www.daverci.com/http://www.ii-i.com/http://www.mede-care.com/http://www.quickmar.com/
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23.11 11
SAMPLES OF eMAR PRODUCTS
DAVERCI
ARTROMICK eMAR