Lecture 5 - Inpatient pharmacy practice and medical records Flashcards
what is the purpose of the joint commission?
to maintain the standards of healthcare. they “check up” on facilities and accredit them
differentiate between a centralized and decentralized hospital
centralized —- one pharmacy serves the entire hospital
decentralized —- one central pharmacy and many “satellite” pharmacies
the pharmacy and therapeutics committee is chaired by ____ and usually cochaired by _____
chaired by a physician and cochaired by the pharamcy director
what is the duty of the pharmacy and therapeutics committee
to make important decisions/changes for the hospital formularies, policies, and procedures
besides the pharmacy and therapeutics committee, name some other committees
infection control
quality improvement
falls prevention
antibiotic stewardhsip
anticoagulation
what are some things that a hospital pharmacist can do
IV TO PO conversion
renal dosing conversion
therapeutic interchange or formulary interchange
anticoagulation monitoring (warfarin)
antibiotic surveillance
consult
vancomycin and aminoglycoside dosing
what is med rec? (medication reconciliation)
comparing the patient’s current list of medications against the physician’s orders
who administers medication to patients in the hospital
nurses
what are the 4 steps of the medication order process (include the 5th step if the script was paper)
order
transcribe (not in e systems)
verify
dispense
administration
what is the “indication” of a medication
why the person is taking it
what does CPOE stand for
computerized physician order entry
is there anything wrong with
“apply to the affected area”
YES
the nurse needs to know where to put it. prescriber must be contacted
medications in hospitals are dispensed as….
unit dosing
What are the 3 ways in which a medication can be delivered to a patient
-by hand (by the technician)
-robot
-pneumatic tube system
who ADMINISTERS medication
the nurse
what is used by nurses to verify that they are giving the correct medication to the correct patient?
bar coding
what is a medication error?
any PREVENTABLE event that may lead to innapropriate med use or patient harm
where do most errors occur in the medication cycle?
(choices: ordering, transcribing, dispensing, administration)
ordering
category A-I medication errors
which is the an error that may have contributed or resulted in the patient’s death?
category I
categery A =
category B-D =
categriy E-H =
A = no error
B-D = error, no harm
E-H = error, harm
I = error, death
if a presciber wants to order a 5 mg tablet of acetaminophen, how should he write it?
5.0
5
5
NO TRAILING ZEROS
A prescriber wants to write for 0.5 mg. how should he write it
.5
0.5
0.5mg
is QD and QOD allowed in writing inpatient medication orders?
NO
what is the purpose of the medical record
-tool for cimmunication btwn healthcare providers
-billing and reimbursement of claims
-legal proceedings
–eduation
-quality assurace
what are the 2 kinds of medical records
paper charts or folders
EMR (electronic medical record)
what are some advantages of EMR over paper
legible
spell check
disaster recovery
-mutiple people can use chart at the same time
-accessibility
-space savings
-drug-drug and drug-allergy interaction checker
what are some DISADVANTAGES of EMR
-cost of implementing the system
-training
-power outage/tech issues
-risk for data breach
-CUT AND PASTE ERRORS
what is the organization that allows healthcare providers greater patient access to information geenerated at other facilities?
RHIO —- regional health information organization
what is the largest public health information exchange, serving NYC and long island
healthix
_____ has the claim to the medical records, but they ultimately belong to _______
HOSPITAL has the claim, but they ultimately belong to the PATIENT
What is on the “face sheet” of a medical record
patient medical record number and patient demographics
what is on the “H&P” portion of the medical record
health and physical
patient demographics
chief complaint
present illness
medical history
surgical history
home meds
allergies
social history
family history
ROS (review of systems)
PHYSICAL EXAMINATION (PE)
impression/assessment
plan
what is on the ROS “review of systems”
what the PATIENT TELLS US
ie: im nauseous and have chest pains
what does MAR stand for and what is it
medication administration record
record of the medications administered to the patient
pharmacists use this to determine if a patient received the drug, at what time, and how often the patient is using a prn medicaiton
the MAR should include which things
time of administration
nurse who administered
route of administration
reason for administering PRN med
reasons for NOT administering (ie: pt refuse, blood pressure too low)
pain scores, fingerstick blood glucose
“im nauseous”
s
“start cephalexin 500mg q 8 hours x 10 days”
p
“based on the findings, pt has a UTI”
A
order repeat CBC
p
right ankle is tender to the touch
o
CXR is suggestive of pneumonia
A
fasting blood glucose = 110mg/dL
o
what is BMP
basic metabolic panel
provides info on electrolytes, renal function, metabolic state
what is CBC
complete blood count
one of the most commonly ordered blood tests
what is UA
urinalysis
what is usually the FIRST set of labs ordered
BMP (basic metabolic panel)
what is one of the most commonly ordered blood tests
CBC
How does a pharamcist use a medical record
5 steps of care process
collect
assess
plan
implement
follow up - monitor + evaluate
when should patient data collection occur
pre-encounter
mid-encounter
post-encounter
where in the chart can you find the ECG
cardiology
where in the chart can you find insurance information
dashboard/face sheet
where in the chart can you find “pt smokes 1.5 packs a dat”
social history
where in the chart can you find “chest clear to auscultation”
physical exam or progress note
where in the chart can you find the comprehensive metabolic panel
labs
where in the chart can you find the psychiatry consult note
consultaitons
where in the chart can you find DNR documents
legal
where in the chart can you find next of kin
family history
where in the chart can you find the list of home medications
H&P
(history and physical) but this would be in the history part
where in the chart can you find the weight of the patient
many places
initial history
physical
