PREADMISSION CLINIC (PAC) BEST POSSIBLE MEDICATION HISTORY (BPMH) MEDICATION INSTRUCTIONS PRE-PROCEDURE MEDICATION INSTRUCTIONS

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Rudolf Allison
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1 PREADMISSION CLINIC (PAC) BEST POSSIBLE MEDICATION HISTORY (BPMH) AND PRE-PROCEDURE MEDICATION INSTRUCTIONS BALL POINT PEN, PRESS FIRMLY DO NOT DO NOT DO NOT D/C disharge or disontinue > or < greater than or less than ml trailing zero ( χ.0 mg) never use zeros after deimal µg mg lak of leading zero (. χ mg) always use zeros before deimal write generi drug name Family Dotor: Speialist: Community Pharmay: Other: Mediation Administration Reord Disharge note/lini visit Mediation vials/ontainers Ontario Drug Benefit Drug Profile Viewer Patient reall Family TAKE DAY OF PROCEDURE Patient weight kg and height m STOP PRE-PROCEDURE MEDICATION INSTRUCTIONS DATE OF LAST DOSE (YYYY/MM/DD) ACTUAL or ESTIMATE (irle one) PRE-PROCEDURE MEDICATION INSTRUCTIONS All mediations HELD on day of proedure unless indiated below. INITIAL HISTORY OBTAINED BY: DATE (YYYY/MM/DD): TIME: MEDICATION INSTRUCTIONS PROVIDED BY: DATE (YYYY/MM/DD): TIME: BPMH REVIEWED AND VALIDATED DAY OF PROCEDURE: DATE (YYYY/MM/DD): TIME: Do not opy or send this page to Pharmay (2012/07/12) - DO NOT THIN FROM CHART - Page # of DISTRIBUTION: Page 1 (White) - Patient Care Order setion Page 2 (White) - Copy to Pharmay, Patient Care Order setion Page 3 (Blue) - Protetor in front of Patient Care Order setion

2 BEST POSSIBLE MEDICATION HISTORY and RECONCILED POST PROCEDURE ADMISSION MEDICATION ORDERS BALL POINT PEN, PRESS FIRMLY DO NOT DO NOT DO NOT write generi drug name Family Dotor: Speialist: Community Pharmay: Other: Mediation Administration Reord Disharge note/lini visit Mediation vials/ontainers Ontario Drug Benefit Drug Profile Viewer Patient reall Family D/C disharge or disontinue > or < greater than or less than ml trailing zero ( χ.0 mg) never use zeros after deimal µg mg lak of leading zero (. χ mg) always use zeros before deimal RECONCILED ADMISSION MEDICATION ORDERS CONTINUE Patient weight kg and height m RECONCILE MODIFY HOLD DISCONTINUE ACTUAL or ESTIMATE (irle one) Speify hanges to HOME mediations ONLY in setion below. (e.g. derease atenolol to 12.5 mg one due to low BP) MEDICATION CHANGES & RATIONALE P INITIAL HISTORY OBTAINED BY: DATE (YYYY/MM/DD): TIME: PROCESSOR S INITIALS: DATE (YYYY/MM/DD): TIME: NURSE INITIALS: DATE (YYYY/MM/DD): TIME: COPY HAS BEEN SENT TO PHARMACY: DATE (YYYY/MM/DD): TIME: Initials: BPMH REVIEWED AND VALIDATED DAY OF PROCEDURE: DATE (YYYY/MM/DD): TIME: PRESCRIBER S PRINTED NAME / COLLEGE OR MEDICAL DIRECTIVE # / SIGNATURE / DESIGNATION / CONTACT #: DATE (YYYY/MM/DD): TIME: (2012/07/12) - DO NOT THIN FROM CHART - Page # of DISTRIBUTION: Page 1 (White) - Patient Care Order setion Page 2 (White) - Copy to Pharmay, Patient Care Order setion Page 3 (Blue) - Protetor in front of Patient Care Order setion

3 TO BE D WITH TRANSFER, POST-OPERATIVE AND DISCHARGE RECONCILIATION BALL POINT PEN, PRESS FIRMLY DO NOT DO NOT DO NOT write generi drug name Family Dotor: Speialist: Community Pharmay: Other: Mediation Administration Reord Ontario Drug Benefit Drug Profile Viewer Patient reall Disharge note/lini visit Mediation vials/ontainers Family D/C disharge or disontinue > or < greater than or less than ml trailing zero ( χ.0 mg) never use zeros after deimal µg mg lak of leading zero (. χ mg) always use zeros before deimal POST ADMISSION MEDICATION FOLLOW-UP Patient weight kg and height m ACTUAL or ESTIMATE (irle one) DOCUMENT COMMENTS AND/OR FOLLOW-UP ACTIONS FOR NEWLY REPORTED HOME MEDICATIONS (Post Admission) (e.g. disovered phenytoin 3rd day, Dr. notified, order reeived) DETAIL ACTIONS TAKEN INITIAL AND DATE INITIAL HISTORY OBTAINED BY: DATE (YYYY/MM/DD): TIME: BPMH REVIEWED AND VALIDATED DAY OF PROCEDURE: DATE (YYYY/MM/DD): TIME: BPMH REVIEWED WITHIN 24 HOURS BY: DATE (YYYY/MM/DD): TIME: (2012/07/12) - DO NOT THIN FROM CHART - Page # of DISTRIBUTION: Page 1 (White) - Patient Care Order setion Page 2 (White) - Copy to Pharmay, Patient Care Order setion Page 3 (Blue) - Protetor in front of Patient Care Order setion

4 AND RECONCILED ADMISSION MEDICATION ORDERS - GUIDELINES FOR ON ADMISSION THE PURPOSE OF THIS MULTIDISCIPLINARY FORM IS TO: Ensure the BPMH is obtained, doumented and maintained on this form only and then filed in one plae in the patient hart (Patient Care Order setion) Doument reoniliation of home mediations with Admission Mediation Orders Allow the Presriber to review the BPMH prior to writing Mediation Orders at all transition points throughout the patient s stay (Admission, Transfer and Disharge) MEDICATION RECONCILIATION STANDARD PRACTICE Mediation Reoniliation is a shared responsibility between Medial Staff, Nursing and Pharmay All admitted patients (> 24 hours) will have a ompleted BPMH prior to Admission Mediation Orders being written INITIATION OF THE RECORD: Initiated by the first Regulated Health Professional assessing and doumenting the patient s mediation history Completion of this BPMH meets the requirement for doumentation of the patient s mediation history To avoid dupliation or onfusion, the person ompleting this form then writes See BPMH on other douments where mediation history may have been previously reorded COMPLETING THE FORM PAGE 1: PREADMISSION CLINIC (PAC) BPMH & PRE-PROCEDURE MEDICATION INSTRUCTIONS Complete BPMH on left side of form inluding: all presription mediations, over-the-ounter (OTC) mediations, herbal preparations, supplements (e.g. vitamins, minerals) When doumenting multiple mediations, initial beside the first mediation, arrow down to the last entry and initial beside the last mediation Sign and date Initial History Obtained By box Presriber/Delegate will review home mediations and use the hek boxes found under the Pre-Proedure Mediation Instrutions setion to indiate mediations to take on day of proedure and/or mediations to be stopped prior to proedure. Presriber/delegate to speify date of last dose for stopped mediations. Note: all mediations are held on the day of proedure unless otherwise indiated in this setion. Presriber/Delegate providing pre-proedure mediation instrutions is to sign and date Mediation Instrutions provided by box DAY OF SURGERY/PROCEDURE: The BPMH is reviewed and validated prior to proedure To hange an entry on the BPMH draw a single straight line through the original entry and initial. Add the orreted information on the next available line, initial in the olumn to the right of your entry. When all hanges and new mediation information have been doumented, sign and date the Additional History Information Obtained By box, followed by the BPMH Reviewed and Validated Day of Proedure box If there are no hanges required, sign and date BPMH Reviewed and Validated Day of Proedure box only PAGE 2: and RECONCILED POST PROCEDURE ADMISSION MEDICATION ORDERS Presriber/Delegate to reonile all home mediations and write post-operative admission orders using the olumns provided (Continue, Modify, Hold or Disontinue) Modifiations to home mediations and rationale for the hanges must be doumented in the Mediation Changes and Rationale setion (right side) Presriber to print name, sign and date in Presriber box bottom of page PAGE 3: Blue opy of Form (To be plaed in page protetor) The BPMH is reviewed within 24 hours post proedure and signed off in box provided To hange an entry on the BPMH draw a single straight line through the original entry and initial. Add the orreted information on the next available line, and initial in the olumn to the right of your entry. To add information about home mediations after the Admission Orders have been proessed, doument the information on the next available line on the left side of page, and initial in the olumn to the right of your entry. Add Presriber notified and any ations taken to reonile any new home mediation information in the setion titled Detail Ations Taken. Then initial and date in the olumn to the right of your entry. Sign the Additional History Information Obtained By box at the bottom of the page. INSTRUCTIONS TO BPMH (BLUE COPY) WITH TRANSFER, POST-OPERATIVE & DISCHARGE FORMS Print eletroni Transfer Mediation Orders, Post-Operative Mediation Orders or Best Possible Mediation Disharge Plan and Presription(s) form Compare and reonile mediation orders on these forms with the BPMH (blue opy) and Mediation Administration Reord (MAR) using the olumns provided (Continue, Modify, Hold or Disontinue). Inlude rationale for any hanges in the setion provided. On disharge, disontinued mediations from BPMH must be transribed to the Best Possible Mediation Disharge Plan and Presription(s) form and reoniled (Resume, Modify, Cont. to Hold or Disontinue) (2012/07/12)

St. Michael s Hospital Medication Reconciliation Learning Package

St. Michael s Hospital Medication Reconciliation Learning Package What is Medication Reconciliation? A formal process which begins with obtaining a complete and accurate list of each patient s home medications