Completing a Medication History Inpatient Nurses

Transcription

1 Completing a Medication History Inpatient Nurses Inpatient nurses may complete a medication history completing the following steps: Open the patient s chart Click the Ad hoc button Double click the Nursing Admission History form or the Admission form appropriate to your area Click the Med History page on the menu Documenting No Known Home Medication 1) Click the Document Medication by Hx button. Notice the status has a blue circle with a white exclamation point which means it needs to be completed. Do NOT click the Add button. The Add button on this screen only allows you to enter inpatient medication orders NOT historical medications. 2) Click the No Known Home Medications checkbox 3) Click the Document History button User Handouts\Medications\Medication History Inpatient Nurses\Completing a Medication History - Inpatient Nurses docx 1

2 Notice the Meds History status has a green checkmark point which means it is complete. If the green checkmark is there when you enter the patient s chart it means someone has already completed the Medication History on this patient and you don t need to do it again. 4) Click the Medication List tab on the Menu then click the Medication History selection in the View panel to see the history Information will display indicating when the last medication history was taken and who took it. Documenting Unable to Obtain Information to Complete a Medication History 1) Click the Document Medication by Hx button. Notice the status has a blue circle with a white exclamation point which means it needs to be completed. Do NOT click the Add button. The Add button on this screen only allows you to enter inpatient medication orders NOT historical medications. User Handouts\Medications\Medication History Inpatient Nurses\Completing a Medication History - Inpatient Nurses docx 2

3 2) Click the Unable to Obtain Information checkbox 3) Click the Document History button Notice the status still has a blue circle with a white exclamation point however the comment indicates the nurse was unable to obtain information to complete a medication history. This same information will display on the Medication List tab. 4) Click the Medication List tab on the Menu then click the Medication History selection in the View panel to see the history Information will display on the Medication List tab indicating that the nurse was unable to obtain a medication history and the date and time of the documentation. User Handouts\Medications\Medication History Inpatient Nurses\Completing a Medication History - Inpatient Nurses docx 3

4 Documenting a Medication History with Compliance Comments Documenting Medications as Still Taking, as Prescribed 1) Click the Document Medication by Hx button. Notice the status has a blue circle with a white exclamation point which means it needs to be completed. Do NOT click the Add button. The Add button on this screen only allows you to enter inpatient medication orders NOT historical medications. 2) Select the medications on the list that the patient is Still taking as prescribed Use the Shift key on the keyboard to select consecutive medications on the list. Use the Ctrl (control) key on the keyboard to select non-consecutive medications on the list. 3) Right click and select Add/Modify Compliance from the Menu selections User Handouts\Medications\Medication History Inpatient Nurses\Completing a Medication History - Inpatient Nurses docx 4

5 When the order details are filled in that information will display in the columns to the right of the selected medications (e.g. Last Dose Date/Time, Information Source, Compliance Status). 4) Leave the Status as Still taking, as prescribed Change the Information source as needed Enter Last dose date/time if known Documenting Medications as Not Taking as Prescribed 1) Select the medications on the list that the patient is Still taking, not as prescribed Use the Shift key on the keyboard to select consecutive medications on the list. Use the Ctrl (control) key on the keyboard to select non-consecutive medications on the list. 2) Right click and select Add/Modify Compliance from the Menu selections 3) Change the Status to Still taking, not as prescribed using the drop down arrow Change the Information source as needed Enter Last dose date/time if known Type a comment in the Comment field. A comment is required on all Still taking, not as prescribed entries. User Handouts\Medications\Medication History Inpatient Nurses\Completing a Medication History - Inpatient Nurses docx 5

6 When the order details are filled in that information will display in the columns to the right of the selected medications (e.g. Last Dose Date/Time, Information Source, Compliance Status). Completing Prescription and/or Historical Medications Complete o Use this option on historical medications when a patient indicates they are no longer taking the medication. o Completing medications removes them from the patient s medication list. o Do NOT complete prescription medications unless the original order states it will be completed within a certain time frame (for example the patient is finished taking a 10 day course of an antibiotic). o If duplicate prescription or historical medications exist on the Medication List, keep the most recent order and complete the other order. o If you are unsure whether to complete an order, use Add/Modify compliance and leave the decision up to the provider or the Pharmacist. Cancel/DC do NOT use this option. Complete medications if they are historical and the patient is no longer taking them and use Add/Modify compliance for prescription medications unless otherwise specified under the complete definition above. 1) Right-click on the desired medication and select Complete from the Menu User Handouts\Medications\Medication History Inpatient Nurses\Completing a Medication History - Inpatient Nurses docx 6

7 2) Click the Sign button to remove the medication from the list. Adding a Historical Medication 1) When you are inside the Document Medication by Hx window, an Add button will be available that allows you to enter historical medications. Click the Add button. 2) Type the name of the medication (generic or brand name) in the Search field. 3) Click on the name of the medication from the drop down list to select it. If the patient only knows the name of the medication but does not know the dose, route or frequency, select the name of the medication only (e.g. Flonase). You do NOT need to select an order sentence with quantities or refill information for historical medications. Click the Magnifying Glass icon if all the medication choices do not display on the drop-down list. User Handouts\Medications\Medication History Inpatient Nurses\Completing a Medication History - Inpatient Nurses docx 7

8 Signing the Medication History 1) Click the Document History button when you are finished taking the medication history. The updated medication list will display in the panel on the Med History window. Notice that this window displays all active medications and all inactive medications 24 hours back so depending on the timing you might see additional medications on the list. 2) Click the Sign button when you are finished documenting. User Handouts\Medications\Medication History Inpatient Nurses\Completing a Medication History - Inpatient Nurses docx 8