T3: Med Rec Flashcards
What is med rec?
A formal process for creating the most complete and accurate list possible of a patient’s current medications and comparing the list to those in the patient record or medication orders
What is the goal for med rec?
Avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.
What are the common errors found in med rec?
1 Omission
2.Commission
3. Errors in dose, strength, frequency, formulation
4. Duplications
5. Intentional vs. unintentional
Don’t assume the patient is taking his/her medications as prescribed
What is the swiss cheese model?
What are the steps of med rec?
- Preparation: Review patient records and develop interview questions
- Verification: Conduct medication history (current meds and new orders)
- Reconciliation: Compare med lists and make clinical decisions (ASEA)
- Documentation: Document changes and update medical record
- Communication: Communicate changes/discrepancies and new med list to patient and appropriate caregivers (including healthcare team members)
What occurs during preparation?
- Review the chart thoroughly.
- Are there any allergies listed?
- Decide what questions you want to ask.
How should you review the chart thoroughly?
- Is there a med list already in the chart?
- What meds were they on previously?
- What are they on now or what should they be on?
- Know what each medication is for.
- Can any of these meds contribute to their current state?
How should we respond to a patient’s allergies?
YES = clarify what their reaction was, how long ago, what the drug was, and if they have had it since then
NO = ALWAYS ASK IF THEY HAVE ANY ALLERGIES
New allergies can develop
What are examples of Med Rec resources?
- MAR
- Patient list or bottles
- Pharmacy
- PMP
- Previous hospital encouter
- Family member or friend
- Caregiver
- Pill identifier
- Drug resources
What is verification?
- Verify patient identity
- Maintain HIPAA compliance
- Ask open ended questions
- Ask about OTCs and various formulations
- Ask about adherence
- Confirm proper device technique
- Confirm patient’s current pharmacy
What are the components of medication history?
- Current prescription medications
- Current nonprescription medications
- Past prescription/Nonprescription medications
- Allergies
- ADRs
- Medication Adherence
What is reconciliation?
- Compare med lists and check
- Use clinical judgment to assess
- Don’t be afraid to ask questions
What are we checking when comparing med lists?
- Ommission
- Commissions
- Dosing errors
- Discontinued meds
- Drug drug interaction
- Drug disease interactions
- Duplications
What should we assess when using clinical judgment?
- Appropriateness
2.Safety - Effectiveness
- Adherence
What is documentation?
- Update the med list in the chart
- Document any recent or recommended changes in the chart
How should we update a med list on a chart?
- Delete old meds or those the patient is no longer supposed to be taking
- Add on any new meds
- Correct meds that are incorrect
What is communication?
- Communicate discrepancies/concerns to the provider.
- Communicate any medication changes to the patient/caregiver.
- Provide the patient/caregiver/healthcare team with an updated med list
When is medication reconciliation most beneficial?
- Admission
- Internal transfer points
- Discharge
- Transitions of care
How is med rec beneficial for admissions?
24-48 hr of admission
How is med rec beneficial for internal transfer points?
- Transfers within a facility
- Most difficult places to implement
How is med rec beneficial for discharge?
Communicate any med changes
How is med rec beneficial for transition of care?
Any changes in setting, service, practitioner, or level of care
What is character for med rec?
- Throughoughness vs incompleteness
- Knowing what factors will diminish the effectiveness of my work or words if neglected
What is chemistry for med rec?
Good communication
What is competence for med rec?
- Good med history
- Asking good questions
