Overview of Medication History and Reconciliation Process 2 Overview of Icons Used in the Medication History 2 and Reconciliation Process The Admission Navigator 3 SureScripts Medication Reconciliation Database 4 Allergies and Immunizations 6 Medication History 7 -Review PTA Medications 7 -Documenting Last Dose 8 -Deleting Medications Already Entered 9 -Changing Medications Already Entered 9 -Adding New Medications 11 Medication Comments 13 Patient s Pharmacy 14 Pharmacy Discharge Planning Note 17 Pharmacy Admission Medication History Note 18 RPH Sign Out Note to Communicate Medication 23 History Status Addendums to Notes 24 Viewing Notes 25 Using Refreshable SmartText to Modify Notes 26 of Interventions using I-vent 27 Quick Reference 29 REV 04/18/16 Page 1
ADMISSION MEDICATION HISTORY AND RECONCILIATION PROCESS OVERVIEW Admission medication histories and reconciliations are performed by the pharmacy staff. The progress of completing the histories and reconciliations is monitored by a series of icons on the Patient Lists. The information collected during the admission medication history is entered into the patient s chart in Epic through the Admission Navigator. Each completed piece of the process triggers changes on the Patient Lists. Overview of Icons and Patient List Displays Used in the Medication History and Reconciliation Process Each time a step is completed in the history process, the icon or Med List descriptor will change. When the process is complete, a green light will display. New Icon Tooltip Text Not Started Not Started History and rec complete; No note filed Note filed, rec not complete Note filed, rec not complete Complete Of note: Bedded outpatients, Extended Recovery outpatients, and observation class patients will display with a shaded background. Admission Med List Status column REV 04/18/16 Page 2
To get started with the admission process, sort your patient list based on Admission Med List Status column. This will put all of your inpatient admissions that need histories done at the top of the list. Patient Class To determine patient class (i.e. inpatient, observation, bedded outpatient, or ERU), click into the patient s chart. The banner on the top will indicate class. The ERU patients medication histories will be completed by the RN. However, these should still be completed by a pharmacist if possible, but are considered lower priority than histories for patients of the other classes. Patients with outpatient and observation class still need to be completed by a pharmacist and are expected to be completed or have a note filed within 24 hours of admission. If the patient s status changes from outpatient to inpatient, the pharmacist is then responsible for completing the Admission Medication History. The Admission Navigator After completing a patient interview, the medication history information is entered into the Admission Navigator. To enter the Admission Navigator, click into the patient, the click the IP Pharmacy button: REV 04/18/16 Page 3
This will open up the inpatient pharmacy functionality, from which the admission, transfer, discharge, and discharge readmission navigators are accessible via the tabs at the top of the screen. The admission tab should default as open. REV 04/18/16 Page 4
From here, you can either scroll down through the admission navigator using the scroll bar, or click on the hyperlinks on the left-hand column to access the area you want to open. SureScripts Medication Reconciliation Database A system that matches patients with their pharmacy prescription benefit coverage, enabling providers to accurately complete medication reconciliation. 1. In the Admission navigator go to. 2. Pharmacy benefits query in progress will display. Click Refresh 3. If No pharmacy benefits on file displays, close the section and move on with the arrival. This does not mean the patient does not have a pharmacy benefit coverage, it simply means SureScripts could not establish a match between patient and a participating prescriptions coverage benefit. 4. The last 90 days of pharmacy medication dispenses will display when a primary coverage has been selected. Note: if a primary coverage has not been selected in the Verify RX Benefits section pharmacy medications will not display. REV 04/18/16 Page 5
5. Pharmacy medication dispenses matching Froedtert & the Medical College of WI orders or medications already on the patient s medication list, will display as Already recorded. 6. Pharmacy medication dispenses not matching a Froedtert & the Medical College of WI order or not currently on the patient s medication list, will display with an Add to Meds button. Click the Add to Meds button to add the medication to the patient s Home Medications. 7. Click the Complete Dispense Report to view 365 days of pharmacy prescription dispenses. REV 04/18/16 Page 6
Allergies and Immunizations As part of the Medication History process, any pertinent information obtained related to Allergies and Immunizations should be added. The Allergies activity allows you to document the type of allergy along with the reaction that occurred. You should document as much information as possible about allergies, reactions, side effects and intolerances. Add unknown if patient does not recall reaction and explain in comments. If patient has tolerated other medications similar add this information in the comments section. The Immunizations activity allows you to document the appropriate dates of vaccinations. The WIR Database is another tool to help document a patient s immunizations. Click on the activity on left side of patient workspace. When data loads, click on hyperlinked patient name. Immunization information can then be added as historical information. REV 04/18/16 Page 7
Enter dates of immunizations for influenza, pneumococcal, tetanus/diphtheria. If the patient knows the month, but not the day of immunization, default to the first of the month. When immunizations entered, click and. MEDICATION HISTORY 1. Review Prior to Admission Medications The Review PTA Meds section of the Visit Navigator displays a list of all the patient s current outpatient medications. When the section is closed, you can see all of the medications in a display-only format. When the section is open, you can add more medications to the list, discontinue a selected medication, change a medication s taking status and use the Informant field to enter who is giving you the medication history. This list of home medications can be sorted alphabetically, by pharmaceutical class, and by prescription vs. patient reported. 2. Documenting Last Dose Taken REV 04/18/16 Page 8
Last dose at the time of history should be populated whenever known. If patient does not remember date or time of last dose, click the unknown button. If patient knows the date but does not know any information about the time leave blank. Examples of when to label home medications as taking, not taking, or discontinued: Taking Patient is currently using the medication on a regular basis, or attempting to take on a regular basis (e.g. poor compliance to regimen or missed dose. Requires some clinical judgment, see scenarios below.). Not Taking Currently prescribed medication that the patient is not actively taking, PRN medication not actively using, or non-compliance. Discontinued The physician has indicated that the patient no longer has an indication that requires the medication, or course of therapy completed. 3. Deleting Medications Already Entered REV 04/18/16 Page 9
To discontinue a medication, hit the red X within the medication list. You will be prompted with a default reason which can be changed to a more appropriate reason for the given situation. 4. Changing Medications Already Entered The house symbol represents that the medication was entered by a physician as a prescription. If medication is clinically incorrect (dose, frequency), delete the order and re-enter correct information as a historical medication o Ex: PCP told patient to cut metoprolol dose in half due to low HR o Ex: Cardilogist increased patient s furosemide from 20 mg daily to 40mg daily For non-clinically significant discrepancies document in the medication history note. o Ex: Patient clarifies that she takes alendronate weekly on Mondays o Ex: Patient states she takes calcium with her evening meal not with breakfast The figure of a talking head appears when it is a historical medication (patient reported). Can freely edit when documenting medication history Adjust fields based on how the patient takes the medication (no need to discontinue the order) Scenario #1 The patient takes cetirizine during allergy season. It is currently summer and the patient has needed the medication daily. Check Taking Since this is an allergy medication and this is allergy season, it is reasonable that the patient is currently taking the allergy medication. REV 04/18/16 Page 10
Scenario #2 The patient uses fluticasone nasal spray during the summer for seasonal allergies. It is currently winter and the patient hasn t used the medication in one month. Uncheck Taking, but do not discontinue the order While the patient may not be currently taking the allergy medication, once the allergy season begins, the patient will resume. The medication should not be discontinued. Scenario #3 The patient ran out of Benicar yesterday because she forgot to pick up her refill from the pharmacy. Check Taking Keep the order active as this medication should be reordered upon admission. Since the patient ran out yesterday, it would be most appropriate to document taking. Scenario #4 The patient admits to not taking his tamsulosin for one month even though he is instructed by his doctor to take the medication daily. Uncheck Taking The patient has been noncompliant for a significant amount of time; the medication has not been discontinued by the physician. You should make a notation in Med Comments to alert the provider. Scenario #5 The patient has not taken her warfarin for five days because she was instructed to hold the medication for her procedure. Uncheck Taking Physician only temporarily stopped the medication Scenario #6 Patient states that his physician told him to stop taking Lisinopril because it was causing him to have a cough. Discontinue the order for that medication physician told him to stop taking the medication indefinitely REV 04/18/16 Page 11
Scenario #7 Patient states they have not taken their metformin for the last three days because they have not been feeling well. Check Taking The patient is using the medication on a regular basis and the last three missed doses are out of the norm. Document when the last dose was taken. Scenario #8 Patient states they probably only take their baby aspirin 4 out of 7 days a week due to forgetfulness Check Taking Although non-compliant the patient is regularly taking the medication on an irregular basis where it could still impact clinical decisions. Make note of when medication was last taken and document patients noncompliance in note. Scenario #9 Patient states they are taking their gabapentin BID while prescription written for TID dosing. Patient taking BID due to misunderstanding. Leave medication entered as TID dosing, educate pt on how they should be taking the medication and document discrepancy Scenario #10 Patient states they are taking their gabapentin BID while prescription written for TID dosing. Patient taking BID due to experiencing adverse effects from TID dosing. Delete medication from list and re-enter as gabapentin BID. Document change in both admission note and med comments so other providers may know why there was a change on the patients medication list. 5. Adding a new medication REV 04/18/16 Page 12
When adding a new medication, begin typing in the Add Medication to List box and search. You will have the option of using a Preference List of medications which you should use whenever possible. If you are unable to find the appropriate medication, use the Database Lookup. Note that the formulary status of the medication is also displayed here. This reflects the Froedtert Hospital formulary. When possible select the version of the medication which is formulary as this will streamline the ordering process for the provider. REV 04/18/16 Page 13
Medication Comments Medication comments display in the Admission Navigator and at the top of the Review Prior to Admission (PTA) Medications section. This section includes an audit trail of all medication comments made. These comments stay with the medication list and are visible to all providers across all encounters. This section is for information that needs to remain with the patient after their discharge. Only document in medication comments if: An issue with patient reliability that will likely be true for a long period or time, and would add value during future encounters (e.g. patient has difficulties with medication compliance due to inability to read) REV 04/18/16 Page 14
When you are finished reviewing and updating the PTA med list, change the Medication List Status dropdown to appropriate option and select the Mark as Reviewed button. Entering a Patient s Pharmacy You may enter the patient s pharmacy within the Prior to Admission Meds section or within the Admission navigator. Clicking on Pharmacy opens the Pharmacy Selection box and allows you to search the pharmacy database. REV 04/18/16 Page 15
The Selection window has been divided into 2 tabs, suggested and search. If the patient has preferred pharmacies or pharmacies that were recently selected, those appear under the Suggested tab. Under the Suggested tab, pharmacies appear with a star icon to indicate whether they are on the patient's preferred list. A yellow star indicates preferred pharmacy where the patient would like to have their prescriptions filled at time of discharge. A white star indicates alternate pharmacy. A patient is able to change their preferred pharmacy during each admission or provider appointment. On the Search tab, the ZIP and State fields are automatically filled in based on the encounter department and the patient's address. A new patient's nearby ZIP Codes check box appears and is selected by default, allowing the clinician to search within nearby ZIP Codes for a pharmacy. REV 04/18/16 Page 16
Once you have found the patient s pharmacy, be sure to choose Add to Preferred List so that the pharmacy is updated into the patient s demographic information. From the Pharmacy Selection box you can add and remove additional pharmacies to the patient s preferred list. REV 04/18/16 Page 17
More than one pharmacy can be selected as preferred, but only the pharmacy that is highlighted when you hit Accept will show in the Patient s Pharmacy activity. Other pharmacies that are added to the Preferred Pharmacy List will show in the patient s demographic information. If a pharmacy is not found in the pharmacy data base, it can be entered in the Medication Comments section. The pharmacy data base is updated periodically and cannot be updated from this entry. REV 04/18/16 Page 18
Entering Discharge Planning Notes All patients should be asked if they are interested in filling discharge prescriptions at Froedtert. You may also want to add information about insurance concerns or whether or not the patient would like prescriptions to be delivered or picked up from the pharmacy. This information should be communicated in the discharge planning note section of the discharge navigator. Click on the Discharge tab under the IP Pharmacy activity. Scroll down to find the Pharmacy Discharge Planning Note Click on comment to open a dialogue box and add notes. This information will appear in the discharge planning notes column of the patient list. REV 04/18/16 Page 19
Pharmacy Admission Medication History Note When the Medication History is completed the history is recorded as a note in Epic. Click the Create Note Activity. The Pharmacy Admission History Note template will auto load. Scroll to top of note or hit F3 function key to expand to full size window. REV 04/18/16 Page 20
Select F2 key to move from field to field. When you are presented with a yellow background choice, you can choose one option. When you are presented with a blue background choice, you can choose multiple options. Multiple choice selections can be accepted by using the space bar or by right clicking with the mouse. The most common choice will default in for you, but you can deselect it if it does not apply. 1. Documenting medication history source: 2. Documenting reliability: If unreliable or somewhat reliable is slected, document WHY and what inforamtion may be in qustion REV 04/18/16 Page 21
3. Medication Storage: Patient supplied medications can be used during the stay in the following situations: Non-fromulary medication that are not immediately available in an acceptalbe time frame, or non-formulary contraceptives. Pre-prepared doses - that will expire and be wasted if not used. Investigational drug or foreign medication foreign medication for which there is no US substitute. Personal drugs drug containing device (insulin pump) with patient control and ordered by physician to be used at all times. Limited distribution drugs not available for purchase by inpatient pharmacy. Bulk Medications taken by a patient in an outpatient, observations or hospice setting (insulin, inhalers, topicals) 4. Additional Medication Information: Medications recently discontinued, started, changed, or on hold Quantify PRN use Adherence/access issues Discrepancies applicable to inpatient stay REV 04/18/16 Page 22
Examples for what to document under Additional Medicaiton Information Patient prescribed levofloxacin on 08/18/14 for URI and has three days of the regimen remaining Patient is prescribed metoprolol tartrate twice daily but is only taking the medication once daily 5. Immunizations: It is the pharmacists/interns/students responsibility to ask about and document immunizations. 6. Filling preference: Ask patient if they would be interested in using Froedtert s Pharmacy for discharge prescriptions. *Reminder document filling location in Pharmacy Discharge Planning Note in addition to the history note. 7. Education/potential needs at discharge: If issues arise during the medication history process that will need to be addressed upon discharge, be sure to document in medication history note. REV 04/18/16 Page 23
8. Caregiver responsible for medications: Identify the caregiver in charge of the patient s medication management and document in the medication history note. 9. Caregiver need to present for discharge: Per your assessment, if the care giver needs to be present for education at discharge. INTERNS/Students: Click Sign to complete the note. Your note requires a pharmacist to Attest (Cosign). A cosign note icon will automatically appear in the patient list, notifying the pharmacist that a note requires their co signature. Admission Medication History Notes that you file will be seen within the Admission Navigator. REV 04/18/16 Page 24
Notes that are filed via the Admission Navigator will also automatically file to a note type of Pharmacy Admission Medication History. RPH Sign Out Note to Communicate Medication History Status IF YOU ARE COMPLETING A HISTORY IN THE ED, please indicate that you are doing so in the RPh Sign Out Note to prevent the floor pharmacists from beginning the history while you might be in the process of documenting. REV 04/18/16 Page 25
You can add, remove and edit comments in the RPH Sign Out Note through the Patient Summary Activity under Patient Profile. Addendums to Notes Notes which have been filed can be revised by making an addendum to the original note. Highlight the note to be changed and click on the Addendum button. REV 04/18/16 Page 26
A copy of the original note will appear in a new window so that revisions can be made. When all of the changes have been completed, click the Accept button. (Note: any changes to medication documentation should be done through the Admission Navigator first and then an addendum can be made of the original Medication History Note.) The original note can be viewed by clicking on Revision History and then View Details Report. The note and revisions will open in a new window with the most recent revisions first. Viewing Notes Only notes from the current encounter will be viewable from the Notes Activity. Notes from previous encounter can be viewed in Chart Review under the Notes/Trans tab. For REV 04/18/16 Page 27
example, Admission Medication Histories will have an encounter type of Admission and Category type of Pharmacy Admission The full title of the category type can be viewed by hovering over the category type Using Refreshable SmartText to Modify Notes REV 04/18/16 Page 28
Open the Notes Activity Select Addendum Make any necessary changes and click Accept. If the information that you need to change is part of a SmartList or SmartLink, you can reactivate that list and make a new selection using the following steps: Right-click on the list (will be highlighted in yellow or blue if eligible for refresh) **Note: If you made changes in Admission Navigator, you must close the navigator completely before refreshing smart text (e.g. Medications) Select Reselect Smart Values to pick from the list or Make selected text editable to free text in information as shown below. In order to view the changes to the note in chart review, you must hit refresh. REV 04/18/16 Page 29
Documenting Interventions Using I-vents of Admission Medication Histories within the Interventions Activity in Epic will provide a tracking tool for reporting the number of medication histories completed and the time required for each pharmacy intern. If not already selected, add New I-Vent [100447] and My I-Vent [100446] to the Patient List Columns. The following Patient List Columns should then appear: REV 04/18/16 Page 30
Double clicking on the My I-Vent icon, provides a link to the Interventions Activity 1) Opened by: Shows the name of the person opening the intervention 2) Linked Patient: Shows the name of the patient the intervention is linked to 3) Type: Select Medication Reconciliation 4) Subtype: Select Admission Medication History 5) Status: Defaults to CLOSED 6) Time Spent: Defaults to 15 minutes and should be changed to the actual time spent completing the Admission Medication History. REV 04/18/16 Page 31
7) : Can be used to provide any other pertinent details regarding the history 8) Accept: click ACCEPT when completed to save the information Quick Reference Normal Admission Workflow 1. New patient admitted Rx total admission Score Red stop sign icon 2. Interview patient 3. Complete information in Admission Navigator 4. Create and sign Admission History Note 5. Change Medication List Status to 3. Medication History Completed, Reconciliation not started. 6. Document Intervention 7. Discuss with pharmacist REV 04/18/16 Page 32