Home Medication History in Horizon Health Summary (HHS)

Transcription

1 Home Medication History in Horizon Health Summary (HHS) Medication history is longitudinal data which means it - Is retrievable (comes back) with each admission. Medications must be verified and confirmed, edited, or discontinued for each subsequent visit based on patient history. Medication history information is gathered at Admission as part of the patient s medical history. This information is used in the Medication Reconciliation process. A. Entering Medication History on a patient new to Wheaton Franciscan Healthcare 1. Log into Horizon Clinicals 2. Select Patient 3. Select HHS Home Meds from the Horizon Health Summary drop down 4. Click Add If the patient takes no medications or no medication information is available: Click one of the radio buttons at top of the Add Home Medication screen as applicable. 5. Select the Medication name from the Common Medications list or perform a Search Search only using the first few letters of the medication You may need to change the Filter by: choice to find the medication. You can include common misspellings by checking the box. The medication database (formulary) is updated monthly and therefore it is rare that you will not find what you are looking for. However, if you search and the drug is not in the database the Add it as free text link will display. To add the medication: o Ensure that you have spelled the drug correctly in the Search field o Click Search (continued on page 2 ) Page 1 of 6

2 o If no matches were found Click the link (the medication name which you entered in the Search for: box displays to the right above the data fields) o If matches were found but not for this medication Click Clear Type Misc- then the medication name Click Search Click the Add it as free text link Continue to step Select the medication name If the medication is taken orally select the drug presented with oral in the name. The route field is then automatically filled in. 7. Enter data (note: you can use the Tab key to move from field to field) PRN Is the medication used as needed? If yes, select the PRN check box and document indication in Special instructions (i.e. for pain). Indications: Ignore this field. Use Special Instructions to document indications of PRNs. Status defaults to Active. Only use Active or Discontinued as applicable to patient. SE WI users - Do not use Held o If you select Discontinued status a reason needs to be provided. Note: If you choose Duplicate or wrong data, Wrong Medication or Wrong Patient the med will disappear from this patient s profile. Reason Applicable when medication is Discontinued or Held. Choose the reason from the drop down provided. Page 2 of 6

3 Special Instructions Use for Patient instructions. Enter as applicable. Enter Start and Stop dates in this field. Special Instructions print on Med Rec and on the Discharge Med List. Comments Internal use only. Could use for a comment such as patient unsure of dose. Comments print on Med Rec but not on the Discharge Med List. General tab Ignore this tab. Discharge tab Complete the following fields at discharge: o Last Given o Next Dose Due Source tab select how history was reported if it is different than the history informant. Select how history was reported. Use drop down list. Example if verified with patient s external pharmacy choose Pharmacy. 8. Select Save or Save and Add Another (repeat process until all meds are entered) Note: if a patient is on different doses of the same med at different times, each must be entered in separately (ex. Prednisone taper). B. Entering Medication History on a patient with history at Wheaton Franciscan Healthcare 1. Select Patient 2. Select HHS Home Meds from the Horizon Health Summary drop down to display list 3. Needs Review is listed in Confirm column (ignore the Verify column as this is used b Pharmacy). Review list with patient. 4. Update list according to patient and/or informant information: a. Add new meds if applicable (Follow steps A.1. through A.8) 5. Double-click on EVERY medication: a. Fill in Last Taken and Taken as Directed? fields in the Admission tab. b. Edit other fields for the med as applicable. Edit the data then click Save. c. Discontinue meds if applicable by selecting the med to discontinue and selecting Discontinue button. You can also double-click on the med and in the Edit Home Meds window change the Status to Discontinued. 6. CONFIRM all the Active meds to indicate the list is current. THIS IS VERY IMPORTANT a. After med list is updated select only the Active Meds by using the drop down in upper left corner of the Home Meds screen. b. Click on first Active med, hold the shift key down on the keyboard and then click the last med. Active meds are now highlighted in yellow. c. Click the Confirm button at bottom of the screen. Confirming indicates that the medication list is current. Your name, date/time will now display for all the Active meds in the Confirmed column. Page 3 of 6

4 C. Interface with Horizon Emergency Care (HEC) and Horizon Ambulatory Care (HAC) Physicians enter prescriptions into a Prescription Writer which will pre-populate some of the fields you see in HHS Home Meds. The Dose and Freq/Rate fields will be blank. However, the information is displayed in the SIG box. The Dose and Freq/Rate from the SIG box will print on the Med Rec and Home Medication Lists. See Figure 1. Figure 1 - screen that displays when you first double-click on the med In the Emergency Department a Work or School excuse can be entered for a patient. These will display in the HHS Home Medication list. Discontinue them when doing an admission history. D. Combination Drugs The Dose field does not accept a slash ( / ). It only accepts decimal points. In the dose enter number of pills then enter tablet as the Dose unit. Select the Strength Page 4 of 6

5 E. Half tabs You can not use a / slash but are able to use decimal in the Dose field. If the patient takes a half-tab you must enter the dose the patient is taking. In the example to the right the patient states she takes ½ of an 81 mg tablet At Discharge, use the Special Instructions to indicate how to properly take the medication. You do not need to use the Special Instructions in the drop down. Simply type in the box. F. Same medication but different doses enter each dose as a separate medication entry. G. Generic vs. Trade Name You will receive a warning if you attempt to enter the same medication again. You receive the same warning if you attempt to use the generic name and the trade name exists in their list (or vice versa) H. Changing a Discontinued medication to Active Select All Meds or Discontinued Meds from the drop down provided in left corner of HHS Home Meds Double click on the medication you want to change the status of Change status to Active Update fields (dose, frequency, etc.) as appropriate. Options are: 1. Edit the existing medication 2. Add this is a new medication example: patient takes different amount of the medication on select days (i.e. Coumadin 5 mg on M, W, F and 2.5 mg on T, TH, S, SU) I. View detail panel To view more detail select the Medication then click this box (put in screen shot). The detail window appears at bottom of screen. You can choose the Detail tab to view the detail of the medication. You can choose the History tab for history of edits for the medication selected. Page 5 of 6

6 J. Filtering All of the patient s med regardless of status will appear in their history for life. The list can become long and confusing. To sort the history you can use several tools: The first drop down allows you to display All Meds, Active Meds, Held Meds and Discontinued Meds. The grouped by: drop down allows you to display the meds by Type (i.e. prescription vs. over the counter), Status (i.e. active vs. discontinued), Confirmed (confirmed vs. not confirmed). Ignore the Reviewed Status at this time. If you check the View detail panel box the detail of the medication you are highlighted on will display in the lower bottom of the screen. This allows for review of the information without going into the Edit screen. K. Discharge Process Update medication list based on Physician orders o Discontinued medications: Click on the med that is to be discontinued. To choose more than one, click one med then hold down CTRL key while clicking the others. Click the Discontinue button at bottom of screen. Reason defaults to Provider Order (change if warranted). Click second Discontinue button. All meds selected will change from Active to Discontinued. o Medications ordered for home: double-click the med and fill in Discharge tab as indicated here: If entering in tapering doses you must make an entry for each dose then type the dates and times to take the dose in the Special Instructions field (i.e. Start and Stop times) L. Printing Reports Reports have been created to use for the Medication Reconciliation process. Discharge Med List - A report is given to patient s at discharge with a list of their new home medications. Therefore, when entering data in HHS Home Meds be sure to use patient friendly terminology. From the Report menu select the report you desire. Click SEND and then RETURN. M. Exiting the application - Right click on the tab then click Close. Although you can keep it open and when done in Horizon Clinicals simply Logout of CAF. W:\All Regions\WFH EHR Education\000 Applications\HHS\0 Tipsheets\HHS Home Meds Tipsheet SE-WI.doc Rhorton 5/18/11 Page 6 of 6