Point of Care: Medication Pass with Pre-Pour

Transcription

1 Point of Care: Medication Pass with Pre-Pour This manual covers completion of a Medication Pass with Pre-Pour in Point of Care. Click the Pre-Pour icon on the Point of Care home screen. Enter the time that you want to Pre-Pour for and click Next. Once a Med Provider is selected, you will see a listing of residents with medications due in the passing window selected for Pre-Pour. This listing will include residents with medications due during the selected passing window. This is usually 1 hour before to 1 hour after the scheduled passing time. Note: The passing window is setup for each community. Click on the resident name to select.

2 Residents will be on the Select a Resident screen if they have any routine medications due during the selected passing time or PRN medications without results recorded. Note: PRNs waiting results will remain on this list until the results are recorded or up to 24 hours. Results cannot be recorded during pre-pour. Once you select a resident, a listing of medications that are due within this Pre Pour window will be displayed. The tabs are for Scheduled, Recent PRNs, and Allergies. The Medication column lists the Medication/Strength or Treatment Name, Instructions, Indicated For and Record at Passing. Selection of Medications to Pre-Pour: To select the medications you are going to set up, click anywhere on the line that contains the medication. Note the change to the Scheduled tab after selecting medications. If you are using a scanner, you will see Scanned in the Select column rather than the X. Once you have set up the medications for this resident, click Med Poured. Point of Care: Medication Pass with Pre-Pour Revised 1/19/13 2

3 You will then see the Status column update with the time poured, your initials, and the word Poured. Click Select Resident or press the F1 key to continue to set up medications for all residents with meds due during the selected passing window. Once you have set up for all residents at that time, you will see the following alert. This completes the setup of medications for the selected passing window. Click Close to return to the Point of Care home screen. Selection of Medications to Administer: Click the EMAR icon on the Point of Care home screen. The Select a Resident screen will open. This listing will include residents with medications due during the current passing window. This is usually 1 hour before to 1 hour after the scheduled passing time. Note: The passing window is setup for each community. Click on the resident name to select. Click Show All Active if you need to give a PRN medication to a resident not on the list. Point of Care: Medication Pass with Pre-Pour Revised 1/19/13 3

4 Residents will be on the Select a Resident screen if they have any routine medications due or PRN medications without results recorded. Note: PRNs Waiting Results will remain on this list until the results are recorded or up to 24 hours. Medications that have been Pre-Poured will automatically be selected. The tabs are for Scheduled, PRN, Recent PRNs, and Allergies. These tabs will change when medications are selected on the scheduled or PRN tabs or if there are recent PRNs. For example this now shows 1 Recent PRNs. Note: The Record Before Passing items and gather this information before administering medications. Take the medications to the resident. When you return to the computer, you will need to enter any Record Before Passing items and select Med Given or Med Not Given. Record Before Passing: Most Record Before Passing items will be displayed at the bottom of the medication listing after the medication is selected. These are the items that you can record the results for all medications selected. Some Record Before Passing items must be recorded on the medication line these are the Site, Amt, and Other because they could be different for the medications selected. Site, Amt, and Other are not shared as these could require different responses on medications selected at the same time. For these Record Before Passing items, you will see them listed in red in the Passing column. Click to record your response. Click where you see <Click here to record >. Point of Care: Medication Pass with Pre-Pour Revised 1/19/13 4

5 Another window will open to record your response. Click OK to save and return to the med passing window. To edit the Record Before Passing item in the Passing window, click where you see <Click to change>. Click Med Given. If you do not complete the Record Before Passing item(s) you will see the following error. Click OK. Complete Record Before Passing item(s), then click Med Given or Med Not Given again to save. Refused Medications: If the resident refused their medications, click Med Not Given, The Med Not Given Reason window will open with your options to select the reason not given. Double click on the reason not given to select, or click on it one time and click the select button. You will not be able to modify this list in Point of Care. Note: If the resident takes some of the medications, but not all of the medications, deselect the medication(s) they did not take by clicking on the medication before clicking on the Med Given button. Then reselect the medication(s) that Point of Care: Medication Pass with Pre-Pour Revised 1/19/13 5

6 were refused and click on Med Not Given. Select the Med Not Given Reason from the following window. Medication(s) given will show the passing time and the initials of the employee giving the medication in the Status column in green. Medication(s) not given will show the date & time of recording and the word Held in red in the Status column. Once you have completed passing this resident s medications click Select Resident or press the F1 key on the key board to bring up a list of resident names to select the next resident. Continue until all resident s medications are charted. When completed with your medication pass for this passing window, click Finish. Or if you click Select Resident, you will receive an alert on the screen stating There are no resident with Meds Due or waiting for results. Once the listing of resident names is completed, you have completed your medication pass for this passing window. Recommendation: Sync your data after each medication pass to send your information to the main database and download any changes to resident medications. Refer to Point of Care: Login, Sync, Logout, and Quit manual. PRN Medications: Click the PRN tab to see a listing of the resident s PRN medications and previous pass information. To see the 24 hour history of PRNs, click Recent PRNs tab. Point of Care: Medication Pass with Pre-Pour Revised 1/19/13 6

7 The Recent PRNs will show a record of PRNs given in the last 24 hours. The number in parentheses refers to the number of PRNs that have been given. Note: Recent PRNs information is updated when you close this resident. The next time you select this resident, you will see any additional PRNs given. The last date and time that the PRN medication was given will be displayed in the Prev Pass (Previous Pass) column. Click on the medication to select. If the PRN medication has only one reason/condition to be given, it will automatically fill in the Reason Given (Rsn Gvn) column. If there are more than one reason/condition that a medication can be given, you will see <Click Here to Select> in the Rsn Gvn Column When you click on <Click Here to Select> you will have a list of reasons/conditions to choose from. Click on the appropriate reason(s) and click OK. This is a multiple select choice list. In this example, Headache and Pain were both selected. Point of Care: Medication Pass with Pre-Pour Revised 1/19/13 7

8 Once the medication is given, click Med Given at the bottom of the screen. The date, time, and your initials will show in the Passing column in green and the reason/condition you selected will show in the Reason Given column. The Result column will have <Click here to enter Results> and the PRN tab will change to PRN (2 Waiting Results). When you go back to check the results of the Medication, you will select the resident. Click on the PRN tab and click on <Click here to enter Results>. The PRN Med Results list screen will open, click on the appropriate option. Note: Recorded in Error: Remove should only be used if you recorded that you gave a PRN medication and did not give it. This will remove the record of this PRN medication being given. If you choose Other and click Select you will be prompted to enter a specific reason. Point of Care: Medication Pass with Pre-Pour Revised 1/19/13 8

9 Once the result has been recorded on Acetaminophen, the Date, Time and Initials for the PRN med that you gave in the Prev Pass column and the Result is displayed. Milk of Magnesia still needs results recorded. Medication Needing Refill: When passing medications, you can mark medications needing refill. If your facility uses cycle fill, then you would only use this feature for PRN medications or any bulk fill items that are not part of the cycle fill. For Scheduled or PRN medications the last column in the row is More Click in the More column and a new window will open. Or you can double click on the row to open the window. Check Needs Refill. Then click OK to save. Refill Ordered cannot be selected from here. Now you can see Needs Refill in the More column. Point of Care: Medication Pass with Pre-Pour Revised 1/19/13 9