Med Rec Flashcards
is medicine reconcilliation the same as medicines history
no
what is medication history
taking the history of what the patient is taking and is the first step of the med rec
what is medication reconciliation
process of obtaining an up to date and accurate medication list that has been compared to the most recently available information and has documented any
discrepancies
changes
deletions
additions
resulting in a complete list of medications, accurately communicated
what 4 things does med rec document
discrepancies
changes
deletions
additions
when should medicines reconciliation take place
reconciled at the transfer of care between settings e.g. hospital admission
in which guidelines was med req highlighted as important
National patient safety agency (NPSA)
National institute for health and clinical excellence (NICE)
Care Quality Commission (CQC)
Royal Pharmaceutical Society (RPS)
what can prescribing errors lead to
harm to patients
what is the aim of med rec
when patients are admitted to hospital its important to ensure that important medicines aren’t stopped and that new medicines are prescribed with a complete knowledge of what the patient is already taking
what are the advantage of medication reconciliation
better communication between healthcare professionals
improving the quality and timelines of information available to clinicians thereby leading to improved therapeutic outcomes
improve record keeping
reduce waste medicines
less duplication time
what are the most crucial advantages of med rec
fewer medication related admissions to hospital
reduce risk of missed doses in particular high risk medicines
reduce medication error and adverse drug events
increasing patient involvement in their own care promoting better concordance
what are the 3 cs of medication reconciliation
Collecting information about a patients medications
Checking that the information is accurate by comparing it with other sources of information
Communicating this with the patient and members of the multidisciplinary team looking after the patient
what does the checking step involve
ciritcal appraisal of the information to verify that the medication and the doses are correct and that there are no omissions or duplications.
what should be done when there is a discrepancy in the checking phase
should be recorded so that they can establish a reason
what does communicating involve
telling the paitient carer or other health care professional about any changes made
what does med rec involve
take the drug history
compare that to the list of medicines that was most recently available for patient
identifying any discrepancies between the two and act on that info
what patient pose issues when taking drug history
confused aggressive unconscious or those acutely unwell patients who are hard of hearing language barrier relative or care administering their medicines
what are sources of information we can check
use the patient relative or carers pods case notes previous discharge letter anticoagulant clinic medicines administration record sheet (MARS) reminder charts district nurse nursing home community pharmacist GP phone call GP repeat prescription slip GP practice print out GP letter Hospital pharmacist records Summary Care Records (SCR)
what is the SCR
summary care record, it is an electronic patient summary, it contains key clinic information created and maintained by the patients gp
who can access the SCR
authorised pharmacy staff treating patients with permission of the patient
what does SCR contain
Allergies, Repeat, Acute, Discontinued
what does pod stand for
Patients own drugs
describe med rec for a methadone patient
information from GP, Patient, PODs, supplying pharmacy, key worker at the drug service
information obtained from the patient with supplying pharmacy
inform the community pharmacy
endorse the drug card
what are alarm bell medicines and conditions
anticoagulants steroids OCP/HRT methotrexate bisphosphonates insulin inhalers drug misusers clozapine antibiotics parkinson epilepsy chemotherapy
State the checklist you should attempt to follow
introduce yourself name and role
confirms patients name and DOB
explain what you are going to do and why
ask about allergies
ask if they have brought their medication in or a lit of their medication
ask how they take each individual item
ask if you take any other medication
ask if you take any illicit drugs or are smoke
ask if you had any recent changes in medicines whether it be dose change
