INPATIENT UNIT MEDICATIONS Best Practice Guidelines
Goals Standardize medication entry for narcotic medications Understand the function of IV and continuous medications including subcutaneous medications delivered via the CADD Pump Understand transdermal medication entry and application documentation in the MAR. Understand Infuse actions assigned to Continuous Medication Understand when and how to use effectiveness alerts in the MAR Understand the process for documenting verbal orders for medications and for assigning the orders to the appropriate physician
Narcotic Medication Entry Example Dilaudid 2 mg sublingual every 4 hours Narcotic Medication Entry Must Include the Following Components: Dose 2 mg Route sublingual Frequency every 4 hours Prescriber (Required for Narcotics only) Payor Agency Admin and pre-pour are not required Start Date today Indication required for PRN meds. Enter for scheduled meds if being used off label. Duration- Enter for any med with an end date 30 days (always 30 days for Narcotic medications as a new script is required after 30 days) Schedule Enter times and Enter days fi non qd dosing is ordered Continuous- Select only for Infusing Medications (CADD Pump) Do not Enter Concentration of Medication
Entering Medications that do not match a Standard Dosing Example Dilaudid 2 mg sublingual every 4 hours In the Medication list tap Add then enter the Medication in the Search field. Multiple Standard variations typically used for prescribing will display in the search. If you do not see the Medication in the format in which you would like to Add the Medication, select the Medication displaying with minimal detail, then edit the entry after the selection is made.
NON Standard dose Narcotic Medication Entry To Change the Route, Select the Show all Routes Checkbox, then select the desired route. (Sublingually in this example) Complete the Dose, Frequency, Prescriber, Payor, Start Date, and Duration (30 days) Fields. Enter Schedule (except for PRN, infusing IV or Continuous dosing)
CAUTION!!! The concentration of medication in any liquid form may vary from patient to patient and vary by pharmacy delivery. Verify the concentration of the Medication and the medication order dose every administration. Adjust the total liquid medication to provide only the dose that is ordered.
Infusing IV and Continuous Medications IV/Continuous medications do not contain scheduled or PRN dosing. These medications are infusing IV or Subcutaneous Medications administered via pump. IV/Continuous Medications allow for the addition of Infuse actions in the Medication Administration Record (MAR) All Medications entered with the Route IV will default to the behavior of a continuously infusing medication, unless they are marked as PRN, or IV behaviors are disabled upon medication entry. A PRN Medication with an IV route will display for PRN dosing on the MAR, and will not behave as an Infusing continuous medication. If an IV medication is to be given as a scheduled medication, medication entry, the IV behaviors must be manually disabled during med entry in order for dosing alerts to display on the MAR. Any subcutaneous medication that is dosing continuously must be marked as a Continuous medication in the Medication Entry screen. PRN subcutaneous Boluses given via pump should not be marked as Continuous. The PRN order must be written separately from the scheduled or infusing continuous order.
Cadd Pump Continuous Medication Order Entry Medications Continuously infusing via a CADD Pump must be entered as per the following Example: Morphine 1 milligram per hour infusing subcutaneous via CADD Pump In the Add Medication search, field enter morphine. Select the generic morphine intravenously order as you will not find standard subcutaneous orders Tap the Show all routes box, then Select Subcutaneously Complete the Dose (1 milligram), Frequency, every hour, Prescriber (ordering MD), Start date (today), Duration (30 days) Select the Continuous button.
Continuous IV and Subcutaneous Meds in the MAR Continuous IV and Subcutaneous medications by nature do not include dosing. However the clinician may document observation and status of the site in the MAR. Until there is an entry documenting the status of the Continuous medication on the MAR, a? will display next to that Medication on the MAR To document the status of the IV or infusing medication, tap in the box in the current time row and enter the details in the pop up box.
Adding Infuse Actions to Continuous IV and Subcutaneous Medications Infuse actions allow the user to document the following: Selected actions are added to the MAR flowsheet. Tap in the current time Row to document a completed infuse action, and add an alert for when the next action is due on that item. Expired Infuse actions display on the MAR with a warning bell.
CAUTION!!! The concentration of medication in any liquid form may vary from patient to patient and by pharmacy delivery. Verify the concentration of the Medication in pump Cartridges and the medication order dose every administration or cartridge change. Adjust the CADD pump settings to provide only the dose that is ordered.
Adding Effect Actions Effect actions are a tools to add reminders that the effectiveness of a PRN medication must be evaluated in a specific timeframe. Example; PRN Dilaudid given for pain at 3:32. Set reminder to assess medication effectiveness in 30 minutes Tap the Dilaudid med given to highlight the medication. Select Effect Actions at top of MAR page Set desired alert (30 minutes in this example) and Save Effectiveness row will countdown and warn with time to assess effectiveness. when it is
Documenting Effectiveness of Medications used for Symptom Management. Effect Actions Alerts appear in the MAR when an Effect action has expired After reassessing the medication for effectiveness, tap in the current time row in the flowsheet and document the medication effectiveness. Select a value here Do not enter effectiveness notes here. Document pain, dyspnea or mental status notes in the appropriate forms!
But Wait! You are not done yet! Pain Management If you gave the Medication for Pain, go back to the detailed Pain Assessment in the Care Plan post Medication and reassessment. Select a pain assessment scale, and complete at least 5 qualities of the pain in your pain assessment. Always include a pain score and location if known. Dyspnea Management Go to the Respiratory Assessment in the Care Plan and document the status of Dyspnea post Medication and reassessment. Anxiety/Agitation Go to the neuro/mental status form in the Care Plan and document the patients mental status post medication and reassessment. Constipation Go to the GI (gastrointestinal) form in the Care Plan, post Medication. Document Bowel status. If patient has not has a BM, enter last BM date in the pain assessment as that value displays in the Trending. ADD PROCESS FOR ADDING ALERTS TO REASSESS IN CARE PLAN
Transdermal Medication Entry Example: Scopolamine patch apply transdermal every 72 hours. Enter the Medication in the Add Med Search field in the med list and select the desired form. Complete the Dose, Route and Frequency fields as indicated. If PRN, Select PRN and Enter PRN Reason Enter the Payor, Start date (today) Do not enter duration and Prescriber is not required for medications outside the Narcotic Category. Do not Enter a Schedule even if the patch is scheduled. Proceed to the MAR when the Patch is Applied
Documenting Transdermal Patches in the MAR? next to a Patch in the MAR indicates that a Scheduled patch has not been documented as having been applied When a PRN or Scheduled patch is applied, go to the MAR to document the Patch as applied, enter duration (72 hours) and Site (left ear), then Save. The MAR will countdown patch time on, and warn when the patch is due to be removed or changed (for scheduled dosing). If the patch is scheduled it will display on the MAR Scheduled Medication section. If the patch has PRN dosing it will display in the PRN medication
Medication Order Sets Home Health Foundation has created ordered sets to standardize the entry of the following Medications: 1 Insulin- for sliding scales 5. Oxygen 2. Coumadin for non daily dosing 6. Insulin Pump 3. Prednisone tapers 7. Saline and Hep lock flushes 4. Hospice Comfort kit To access Medication Order Sets Tap the Add Medication button on the Medication lists- then select Order Sets Select the desired Med from the list of Order sets Comfort Kit Order Set contains all the MVH comfort kit medication. Select the Add Comfort kit box to select all medications in the Comfort Kit. If you wish to leave out one or more of the Comfort Kit medications, those meds may be deselected from the list. Tap add Medication. Each selected Medication will pop up fro review, tap save to accept or Cancel if you do not wish to include the Medication on the list. Note that all medications in the Comfort kit are PRN. The PRN reason and Payor are contained in the order set, and do not have to be added by the user.
Order Sets - Coumadin Coumadin- Choose the order set version of the Coumadin Medication for all NON daily dosing. Enter Dose, Route Frequency and Payor- Pay careful attention to frequency and enter the number of days per week that the patient will be taking the Coumadin. Example- Monday, Wednesday, and Friday dosing is a Frequency of 3x/wk, NOT 1x/day on Monday, Wednesday and Friday. Complete the Notes template by entering an X next to the desired days. Use the start date and end date when the dosing is for a finite number of days. Be sure to complete the schedule time and schedule days (enable non qd dosing) in the Schedule tab for HPH patients. Entering the time in the notes box will not create dosing alerts in the MAR
Non Daily dosing In the IPU non daily dosing schedules may be entered in the schedule screen. A full 2 weeks of the dosing schedule must completed in order for the Medication doses to display properly. For example, and every other day order should look like this. Start with the current day of the week, complete through the second week, then backfill the 1 st week. The schedule will repeat every 2 weeks. Don t forget to enter the scheduled time as well for non daily doses.
Insulin Sliding scales In the Add Medication screen, select order sets and choose the appropriate shot acting insulin. Select as many insulin orders as indicated in the scale Example: Humalog sliding scale based on pre meal CBS. Complete the dose, route and Frequency (pre meal=3x/day) and Payor. The PRN box will already be checked and the PRN reason is entered. Add the CBS range in the template in the Notes section, and enter time of day, then Save. Order sets will display together on the Medication list
Order Sets- Prednisone Taper Select Prednisone Taper and select the number of prednisone doses needed for the taper Enter the dose, route, Frequency, Payor, Start Date and Duration for each Prednisone order. Fill in the number of days, start and end dates in the Notes section template also. Proceed to the schedule and enter the scheduled times, and schedule days, then Save. The Prednisone dose will appear with a Clock when it is time to DC that dose
Signing Medication Orders Enter a Quick Note every time you take a verbal order! Orders may be signed as you go by accessing the To Do List in the Patient Banner. Clinical summary should contain only SOC Admission or Recert Summary Any orders not signed at the end of a shift will display in the Shift Sign screen. The Shift signature will apply to the orders as well as the Shift.
Validate Orders Before Signing 1. Verify that each Order is Accurate. 2. Verify that each order is going to the ordering Prescriber Note one exception- If the orders are the initial orders, they must go to the Plan of Care and must be assigned to the primary MD. If you get an order from an NP, during the 1 st shift when the patient is admitted, the order must still be sent to the Primary MD assigned as with all start of care, admission orders. 3. Verify that the order is correctly marked to go to Plan of Care (Original Admission orders) or Interim orders. Orders received after the admission is completed must be marked as Interim orders, as they are changes to the original plan of care. Orders will default to Plan of Care until the Start of Care orders are review signed by QA. If an order defaults to Plan of Care, and a Medication or Intervention is added or DC d after the Admission shift, change the Order to Interim Orders Once an Order is Marked as an Interim Order, the provider to sign can and should be updated, if the Provider is not the Primary MD, which is the defaulting MD for the orders. 3 1 2
New Care Plan Reminder Alerts On the Flowsheet Care Plan screen, when documenting against Interventions (Tasks), users will have the ability to set an Alert so users are aware when the Task needs to be performed again. On the Document Task screen an 'Alert in' field will display allowing users to set an alert. Users have the ability to set the alert for a number of Hours or Days.