Inpatient Prescribing Med Records Flashcards
Types of Inpatient Healthcare Facilities:
Hospitals (General and Specialty)
Rehabilitation Centers
Psychiatric Hospitals
Long-term Care Facilities (Nursing Homes)
other facilities
Residential Treatment Facilities
Hospices
The Joint Commission (TJC):
Mission: Improve safety and quality of care through accreditation and related services.
Sets and maintains healthcare standards.
Conducts facility assessments.
Publishes annual patient safety goals.
Centralized hospital
Centralized: One pharmacy serves the entire hospital.
Decentralized:
Decentralized: Central pharmacy with satellite pharmacies near patient units.Central pharmacy with satellite pharmacies near patient units.
Outpatient Pharmacy
for discharged patients and employees.
Role of Pharmacists on the Medical Team:
Medication reconciliation
ED interviews
Transitions in care (e.g., hospital to rehab)
Discharge counseling
Ensuring appropriate medication usage
Medication Reconciliation
Process of identifying a patient’s medication list.
Compares patient’s list to physician’s orders.
Critical for preventing medication errors during transitions of care.
Medication Errors:
Any preventable event causing inappropriate medication use or patient harm.
Can occur at various stages of the medication cycle.
Commonly result from poor communication.
Medical Records:
Legal documents for patient care.
Aid in communication among healthcare providers.
Serve as proof of events or procedures.
Document complete patient care information.
Pharmacist interventions
Ensure the following
Appropriate medication prescribed
Formulary medications
Appropriate dose of medication
Appropriate route of medication
Appropriate monitoring of medication
Types of Medical Records:
Paper charts or folders.
Electronic Medical Records (EMR).
Components of a Medical Record:
Face sheet
History and physical (H&P)
Consultations
Progress reports
Nursing notes
Lab data
Medication reconciliation
Patient’s orders
Medication administration records (MARs)
Radiology/imaging
Surgical procedures
Review of systems
Physical examination
How Pharmacists Use Medical Records:
ollecting data for patient assessment.
Assessing information.
Planning and implementing care.
Documenting interventions.
Monitoring and evaluating patient progress.
Pharmacy-Related Components in Medical Records:
Allergies, medication history, physical findings.
Laboratory and diagnostic results.
Clinical and treatment notes.
Problem lists.
Medication administration records.
Orders.
How to Collect Data:
Be systematic and organized.
Keep the process simple and relevant.
Avoid over-collecting data.
Be efficient and consistent.
Timing of Patient Data Collection:
Pre encounter assessemnt
Mid encounter assessment
Post encounter assessment
Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Mission: Improve safety and quality of care.
Maintains healthcare standards.
Conducts facility assessments.
Publishes annual “patient safety goals.”
Reasons for TJC Accreditation
Enhances community confidence.
Acts as a marketing tool.
Represents performance improvement.
Required by most residencies.
Attracts qualified staff.
Encourages development.
Acknowledged by some payers.
May reduce liability costs.
TJC Patient Safety Goal #3 - Medication Safety
ocuses on safe medication practices.
Label unlabeled medicines before procedures.
Applies to syringes, cups, and basins.
Label in preparation areas.
Caution with blood-thinners.
Record and share accurate medication info.
Compare all medicines taken.
Provide written info to patients.
Stress bringing an up-to-date list to visits.
Advantages of EMR
Legible notes.
Accessible charts.
Transcription cost savings.
Space savings.
Multiple users simultaneously.
Automatic lab results.
Spell check.
Disaster recovery.
Drug interaction and allergy check.
Enhanced patient safety.
Electronic prescriptions.
Disadvantages of EMR
Cost of implementation.
Transitions in care between systems.
Training required.
Technical issues and power outages.
Security and data breach risks.
Copy-paste errors.
RHIO
Regional Health Information Organization.
Health Information Exchange
Shares healthcare information among organizations.
Improves patient access to data from various facilities.
Healthix
Largest public HIE in NYC and Long Island.
Retention of Medical Records in NY
Must keep records for at least 6 years from discharge.
Obstetrical and children’s records for 6 years or until child is age 21, whichever is longer.
6 years after death.
Based on a legal principle of confidentiality.
HIPAA
Security standards protect data environments.
Privacy standards govern use and disclosure of protected health information (PHI).
Components of a Medical Record
Face sheet.
History and physical (H&P).
Consultations.
Progress reports.
Nursing notes.
Lab data.
Medication reconciliation.
Patient’s orders.
Medication administration records (MARs).
Radiology/imaging.
Surgical procedures.
Review of Systems.
Patient statements.
Physical examination findings.
Consultations
Consultations in various medical specialties, e.g., cardiology, pulmonary, gastroenterology.
Consulting services include pharmacist consults for medication-related issues.
Patient’s Orders
Orders can be initiated by credentialed personnel like nurse practitioners, physician assistants, and physicians.
Orders include laboratory tests, X-rays, procedures, medications, treatments, diet, and activity levels.
Always include any patient allergies.
Progress Notes
Attending physicians, consulting physicians, and consulting services contribute.
Pharmacokinetic assessments, medication counseling, and adverse drug reactions.
Case management and social work notes.
Respiratory therapy and dietary/nutrition notes.
Nursing Notes
Admission assessment, including skin assessment, height, weight, and allergies.
Daily flow sheets documenting physical assessments, vital signs, IV access, intake, output, and weight trends.
Laboratory results with normal reference ranges and interpretations for uncommon results.
Medication Administration Record (MAR)
Purpose: Record of medications administered to patients.
Used by pharmacists to verify drug administration, timing, and PRN medication use.
Documents time, administering nurse, route, and reasons for PRN medication administration.
How Pharmacists Use Medical Records
Collect data (subjective and objective) for patient assessment and care plans.
Assess the data to derive meaningful conclusions.
Plan and implement pharmaceutical interventions.
Document patient-related notes and interventions.
Follow up by monitoring vital signs, labs, and progress toward therapy goals.
Pharmacy-Related Components in Medical Records
History and physical: Allergies, medication history, pertinent physical findings.
Laboratory and diagnostic test results: Disease states, medications, drug concentrations, cultures.
Clinical and treatment notes: Progress notes, nurses’ notes, consultations.
Flowsheets: Daily vital signs.
Medication Administration Record.
Orders.
Data Collection Forms
Forms are customized for specific roles or clinical settings.
Data format varies based on practice setting and provider services.
Factors influencing data collected: clinical setting, patient care team role, task-driven assessments.
