Transcript Initial Patient Assessment

Northside Hospital
Student Orientation
Welcome!!
We are so happy to have you as part of our
team!
We hope that your experience at Northside
Hospital will be a valuable stepping stone in
your career!
Purpose Of This Presentation
• Introduce Northside Hospital services
• Ensure accurate completion of required
paperwork
• Provide information regarding key policy &
procedural issues
About
Northside Hospital
• Opened 1970
• Not-for-profit community hospital
• 444 bed full service hospital
• Named “Most Preferred Hospital” by the
National Research Corporation 4 years in a
row
Proud To Serve...
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Women’s
Oncology
Surgical
Specialty medicine
Emergency
Core Values At Northside
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Dignity
Respect
Pride
Warmth
Caring
Forms
• Must be completed, signed, dated &
returned to instructor before arrival at
Northside Hospital campus
• Acknowledgement and Release Form
• Health History
– All questions must be answered in #6 (TB skin
test) & #7 (Rubella)
Name Badge
• Our policy requires that you wear your
name badge AT ALL TIMES while you are
on the Northside Hospital Campus
Dining At Northside Sandy
Springs
• Two food services
– McDonald’s
– Morrison’s
• 30% discount with your name badge
– Morrison’s: when open (6:30 AM - 7 PM)
– McDonald’s: only when Morrison’s is closed
Dining At Northside Forsyth
• Only one food service, but 30% discount
with your name badge applicable
Parking At Northside Facilities
• Please use the Women’s Center Deck,
located on Hollis Cobb Drive directly
opposite the Women’s Center
• Code required for entry for free parking;
obtained from your instructor
• At Forsyth, use designated employee
parking areas--no code required
Confidentiality
• Critical to maintain because:
– Protect the trust patients have in their health
care providers
– Requirement of Code of Ethics of various
professions
– Required by regulatory & accrediting
organizations
Health Insurance Portability and
Accountability Act…... HIPAA
Enacted to ensure that personal medical
information (shared with doctors, hospitals and
others who provide and pay for healthcare) is
protected.
Establishes new restrictions on uses and
disclosures of personal health information.
Allows patients enhanced protection and greater
access to their medical records.
Organizations (Covered Entities)
that are required by law to follow
HIPAA guidelines.
Examples are:
› Healthcare Providers
› Health Plans
› Healthcare Clearinghouses
› Business Associates who have access to patient
records. ( i.e. Consultants)
Protected Health Information
(PHI)
• Any patient’s health or personal information
transmitted through oral, recorded, paper, or
electronic means.
Such as:
– Patient name and address.
– Social Security Number.
– Medical records.
– Billing information
Minimum Reporting Necessary
• PHI is to only be used or disclosed when it
is necessary to carry out a specific function.
• This standard does not apply when PHI is
used or disclosed for treatment purposes
Our Role for Privacy Notice
• We are required to inform patients of how
we, as a facility, use and disclose their PHI.
• Patients must receive this notice on the date
the first service is rendered.
• The right to access and control the PHI of
minors is left to the parents - except when
state law overrides parental control.
Patient’s Have Rights To:
• Restrict use and disclosure. (Although the provider, NSH, is
not required to agree).
• Designate an alternate means for communication with the
patient (i.e. work number vs home number)
• Inspect and amend their medical record or “state their part
of the story”.
• Request a history of non-routine disclosures for as far back
as 6 years.
• Contact the designated NSH privacy official with questions
and breech of privacy complaints.
Tips On Confidentiality
• Avoid using waiting areas to interview or
brief patients or family members
• Be mindful that there are often patients &
family members on employee elevators, in
hallways & in the cafeteria
Confidentiality & Technology
• Prior to sending a fax, check with the
charge nurse in the department to which you
are assigned
• Don’t leave computer displays showing
confidential information--log-off when
finished
• When using a copier, don’t leave material
unattended
Questions About
Confidentiality Practices
• Ask your preceptor or the charge nurse of
the unit to which you are assigned
HIPAA contacts
• Pat Parker
NSH - all metro Atlanta locations,
Alpharetta, Meridian Mark, John’s Creek
• Anne Reed
NSH Forsyth
Respect and Courtesy At
Northside Hospital
• Knock before entering
• Introduce yourself before observing or
initiating care in any setting
Other Supportive
Services Available
• Patient Relations
• Pastoral Care
• Check with the charge nurse for more
information on utilization or how to access
ENVIRONMENT OF CARE
Seven Elements of the
Environment of Care
• Safety Management
• Utilities Management
• Fire Safety
• Medical Equipment
• Security
• Hazardous Materials
• Emergency
Management
Safety Management
• Hospital Safety Officer: Dial 8784
• Use the emergency number to report all
Code Blue, Safety, Security and Medical
Emergencies.
• A Code Blue is someone who may be
having a Heart Attack or Respiratory Arrest.
Safety Management
• Report all Needle Sticks and Injuries to
your Supervisor.
• Use Standard Precautions when dealing
with patient’s bodily secretions.
• Personal Protective Equipment (PPE) will
be provided at no cost.
Security Management
• There is 24 hour Security on-site.
• “Code Pink” is the Infant Missing Code.
Assist with search for infant.
Security Management
• Escorts are available by calling Security.
• Emergency Phones, Intercoms and Stairwell
Alarms are available in Parking Decks.
• Report all Suspicious Persons to Security.
Fire Safety
• Code Red is the Code for Fire or Smoke.
• Use R-A-C-E if you discover a fire or
smoke condition.
• Rescue:
Your Patient and Yourself
• Alarm:
Pull the nearest Alarm
• Contain:
Close all Doors.
• Extinguish: Use a Fire Extinguisher
Fire Safety
• Report all Smells of Smoke to emergency
number & Alert your Charge Person.
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Use P-A-S-S with Fire Extinguishers.
Pull the pin.
Aim at the base of the fire.
Squeeze the handle.
Sweep the fire.
Medical Equipment
• Notify Charge Person if Medical Equipment
does not seem to be working correctly
• All Electrical Patient Equipment MUST
have a three prong plug and an Up to Date
Safety Inspection Sticker.
Emergency Management
• Code Orange is for Bomb Threats. Report
suspicious items to Security. Do Not Touch
or Move Suspicious Items.
• Code Grey is for Tornadoes. Close & Latch
all Windows. Relocate patients to Inner
Hallways if able. If not, protect patients by
moving them away from windows.
Emergency Management
• Code Green is for External Mass Casualty.
Continue in your present role and follow the
instructions of your Charge Person.
• Bio-Terrorism: Use Standard Precautions
for all patients. smallpox patients will be
placed on Air Control & Contact
Precautions. Plague patients will be placed
on Droplet Precautions.
Hazardous Materials
• Material Safety Data Sheets can be obtained
by contacting your Charge Person or the
Hospital Safety Officer.
• Report all Chemical Spills to your Charge
person.
• Use Personal Protective Equipment
Utilities Management
• Utility Systems include Elevators, Water,
Electricity, Heating,Ventilation and Air
Conditioning.
• Report any problems with Utility Systems
to your Charge Person or the Hospital
Safety Officer.
Environment of Care Summary
• Emergency Number: Atlanta = 8911, Forsyth =
54321
• Security Control Center Number: Atlanta = 8797,
Forsyth = (678) 776-7869
• Code Blue: Cardiac & Medical Emergency
• Code Red: Code for Fires
• Race: Rescue, Alarm, Contain,Extinguish
• Hospital Safety Officer Number: 8784
• Code Pink: Missing Infant
• Use Standard Precautions
INFECTION CONTROL
PRESENTS
ISOLATION
BIOTERRORISM
CLEAN/STERILE TECHNIIQUE
The Isolation Guidelines
Has Two Major Parts
• Standard Precautions
– Precautions for care of all patients regardless
of diagnosis
• Transmission Based Precautions
– Precautions designed for care of specified
patients
EMPIRIC
• Isolate pending confirmation of diagnosis
• Based on experience
• “Educated guess”
Standard Precautions
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Used for all patients at all times
Replaces Universal Precautions
Barrier precautions the same
Use common sense
Standard Precautions
Barriers
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Handwashing
Gloves
Gowns/Aprons
Masks
Goggles
Sharps containers
Ventilation Devices
Standard Precautions Con't.
• Handwashing (Most important prevention)
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Consider waterless when no sinks
before patient care
after removing PPE
between tasks
after patient care completed
Standard Precautions Con’t
• Gloves
– for venipuncture, vascular access, when
touching contaminated items
– clean gloves for mucous membranes & change
often
• Gowns
– to prevent soiling of uniform and skin
contamination when pt. care requires contact
with blood, body fluids or nonintact skin
Standard Precautions Con’t
• Mask & Goggles
– to protect mucous membranes of the eyes, nose
and mouth from droplets of blood or body
fluids
– use anytime there is a potential risk
• THIS MEANS SUCTIONING!!!
Transmission Based Precautions
• Designed for patients known or suspected to
be infected or colonized with transmissible
or epidemiologically important organisms
Transmission Based Precautions,
con’t:
• Three Types:
– Airborne Precautions
– Droplet Precautions
– Contact Precautions
• New precautions called STANDARD PLUS
– Use Gloves to enter room & for all patient
contact
Airborne Precautions Use For:
• Airborne spread, tiny
droplets
• TB - Suspect or
confirmed
• Chicken Pox (Varicella)
– or disseminated Zoster
• Measles - (Rubeola)
• Small Pox - (BT)
• Hemorrhagic
Fevers - (BT)
– (Ebola, Lassa,
Marburg )
Airborne Precautions
• Mask
– use at all times
– N95 for TB & SMALLPOX
– surgical mask for CP & other
• Isolation room needed
– negative pressure
– keep door closed
AIRBORNE Con’t.
• Add CONTACT PRECAUTIONS
– for Chicken Pox , disseminated Zoster &
Smallpox ( Use 2 signs)
– Teach patient to cover nose & mouth when
coughing
Droplet Precautions use for
• Large Droplets
• Acute respiratory infections
• N.meningitides pneumonia caused by :
influenza, Mycoplasma,, parvovirus,
pertussis, Plague
Droplet Precautions Con’t
• Mask
– Surgical Mask is the primary barrier unless
patient has large amounts of secretions or
drainage
– Wear mask when working within 3 feet of
patient
– Wear Mask when suctioning
– Wear mask on patient when transporting
Contact Precautions Used For:
• Drug Resistant Bacteria
– MRSA, VRE &, Others Identified by ICC
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C. Difficile
Major Drainage from wound infections
Diarrhea if patient is incontinent
Highly Contagious skin infections ie:
scabies, lice, impetigo
Contact Precautions
• Wear gloves and gowns when entering the
room
• Remove all ppe before leaving the room
• Transmission by direct pt. contact or
contact with items in the environment
• Create a barrier ALL THE TIME
• May use empirically
Northside Isolation For
Resistance ( Orange Sign)
• Use With Contact Isolation Sign
• Important Points
– Wear all PPE when entering room
– Remove all PPE before leaving
– Don’t touch doorknobs and surfaces after
gloves are contaminated
New Precautions Called
Standard Plus
• Standard Precautions With Gloves
– Wear gloves to enter room and for all contact
with patient
– designed for patients who have a hx of MRSA,
VRE but who have no symptoms of infection,
drainage, or an invasive device in place
Standard Precautions:
Other Components
• Linen - Clean Cover Or Store In Closet
– Never toss on floor
– Never shake
– Consider used as contaminated
• CPR - Masks Available
Standard Precautions:
Other Components
• Waste - Georgia Regs
– Red Bagged
• Fluid filled containers
• Microbiological, pathological
– Tissue
– Rotoclave- Onsite
• Blood Spills - clean up by using gloves,
paper towels and disinfect area
• Sharps - Empty 3/4 Full
Standard Precautions:
Other Components
• Exposures
– First aid
– Report ASAP to Employee Health in off hours
your supervisor / ER/ school
– Source testing
– Pep prophylaxis/vaccine
– Use safety devices
Standard Precautions
• Exposure Control Plan (ECP) In The
Manual
• Tuberculosis Plan
• Vaccines
Bioterrorism
• What Is Bioterrorism?
– Bioterrorism is the intentional use of
pathogenic organisms , (bacteria, viruses, fungi)
or toxins into a community to cause disease
and inflict terror.
– Primary Agents
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Anthrax
Botulism
Plague
Smallpox
Bioterrorism
• What Is Your Role?
– NSH has a bioterrorism plan
– Take directions from your
supervisor
– Apply appropriate isolation
• Standard precautions for all.
• Smallpox - place in airborne/contact precautions
• Plague - droplet precautions
Appropriate Use Of Clean and
Sterile Technique
• Basic Principles
– Microorganisms are capable of causing illness
in humans
– Microorganisms can be transmitted by direct or
indirect contact
– Illness can be prevented by interrupting
transmission
Definition Of ASEPSIS
• Clean technique - refers to practices that
reduce the numbers of microorganisms to
prevent or reduce transmission
• Surgical technique- refers to practices
designed to render and maintain objects and
areas maximally free from microorganisms
Clean Technique
• Reduce numbers of skin microorganisms by
handwashing or cleaning
– Use soap for routine care
– Apply friction to increase amount of soil
removed
– Clean from areas of clean to areas of less clean
Clean Technique (Cont.).
• Barrier techniques reduce transmission from
patient to personnel
– Use no-touch dressing technique to avoid
contaminating sterile supplies
– Use sterile gloves for dressing application
– Wear clean gloves or apron or gown to protect
clothing
– Wear clean gloves to avoid contact with
infectious material
– Room placement important ie: neg pressure
Surgical Technique
• Provide maximum reduction of skin
microorganisms without damaging tissue
• Surgical Scrub
– Cleanse with soap to remove soil
– Use antimicrobial agent: may leave residue to
continue suppression
– Apply friction with scrub brush
Sterile Technique
Provide Maximum Reduction
• Patient Prep
– Use antiseptic agent
– Remove hair when necessary. Note: When hair
removal is necessary, it should be done with a
depilatory or, less desirably , by clipping, rather
than by shaving with a razor.It should be done
immediately before the procedure,
Sterile Technique
• Use barrier techniques to decrease
transmission of microorganisms from
personnel to patient
– Maintain area of sterile field with sterile gloves
gowns and drapes
– Wear appropriate attire as indicated by risk of
procedure and area of hospital where the
procedure is performed
Surgical Technique
– Environmental Controls To Reduce
Microorganisms During Surgical Procedures
Use special treatment rooms
– Control activity to reduce airborne transmission
• Keep doors closed during procedures
• Exclude visitors and unnecessary personnel
• Avoid cleaning activities in the area during surgical
procedures
Reprocessing Equipment
Between Patients
– Discard disposables after each patient use.
– Use mechanical cleaning or change cover of surfaces not
in contact with abraded skin, mucous membranes, or
infectious secretions/excretion (e.g., exam. tables,
stretchers, wheelchairs.)
– Use mechanical cleaning and disinfection of noninvasive
equipment that may become contaminated with body
fluids (e.g., electrodes, ear speculums, stethoscopes, blood
pressure cuffs, outside surfaces of equipment such as
ventilators or intravenous pumps.)
PATIENT’S RIGHTS AND
RESPONSIBILITIES
PARTNERING WITH OUR
PATIENTS AND FAMILIES
Patient Rights
• Patients have the right to privacy,
confidentiality, ethics consultation, refusal
of treatment, safety, interpretation when
needed, assessment & management of pain
and more
• For a complete listing of patients rights, see
“Your Rights and Responsibilities as a
Patient” fact sheet
Patient Responsibilities
• Patient responsibilities include asking
questions, providing accurate information,
following treatment plans and more
Patient Rights & Responsibilities
• Northside encourages patients and families
to be active members of their healthcare
team in order to provide the highest quality
of care
• In keeping with this “partnership”
philosophy, every patient that is admitted to
Northside Hospital receives a written copy
of their rights and responsibilities along
with ways to help prevent medical errors
(available in English and Spanish)
Patient Rights & Responsibilities
• Other patients rights reference materials:
– Patient/Family/Visitors Guides located in all
patient rooms and patient access areas
– Mosby’s Multicultural Reference Guide
• Located on patient care units and in Health Resource
Library
– Multi-Faith Informational Manual
• Located on patient care units and in Health Resource
Library
• Information regarding Northside’s Ethical
Code of Conduct can be found in policy F-018
ASSESSMENT
Initial Patient Assessment
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Physical, psychological, and social status
Nutritional, functional, and educational needs
Department's specific content
Determines the need for care or treatment,
– H & P (done by MD)
• Inpatient: on chart within 24 hrs
• Outpatient: on chart prior to procedure
– Nursing Assessment completion:
• Inpatient: on chart within 24 hrs
• Outpatient: on chart prior to procedure
Patient Reassessment
• Done according to the department's specific
policies and procedures on reassessing
patients.
• Done when
– significant change in the patient's condition
– when a significant change occurs in the
patient's diagnosis.
– According to department specific, patient
specific guidelines
Interdisciplinary Plan of Care
– Shows collaboration and coordination of patient care
among disciplines
– Interdisciplinary Plan of Care is supported by:
• Interdisciplinary Clinical Guidelines
• Standards of practice
• Protocols
Interdisciplinary Plan of Care
• Interdisciplinary Plan of Care includes the
following sections:
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Admission date, diagnosis
Problem identification and prioritization
Consultation visits
Nutrition
Diagnostics
Interdisciplinary Plan of Care
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Activity
Treatments/Interventions
Psychosocial/Spiritual
Patient/Family Education
Discharge Plan
Goals/Outcomes
Interdisciplinary Plan of Care
• Nursing evaluation should reflect patients
progress toward goals/outcome criteria
(achievement or non achievement of the
goals/outcome criteria)
• If a patient does not meet outcome criteria
for identified problems prior to discharge,
they should be referenced in the discharge
education, follow-up, transfer note etc.
Patient Safety-Restraints
• Definition:
– Method of physically restricting a person's freedom of
movement, physical activity, or normal access to his or her
body, including medication.
• Goal:
– Limit use of restraints to situations where alternative
measures have failed & only when the possible benefits
clearly outweigh the risks
Patient Safety-Restraints
• Your role:
– Restraints always require an MD order prior to
implementation
• Restraints used as part of a procedure are not considered a restraint
– Communicate with patient’s nurse prior to any
treatment/procedure/interaction
– Communicate assessment findings relevant to patient’s
behavior to patient’s nurse
– If restraints are removed prior to treatment/procedure, have
patient’s nurse check re-application prior to leaving patient
unattended
Patient Safety-Falls
• DEFINITION: An uncontrolled or unintentional descent
from a higher elevation to a lower elevation
• CAUSE OF FALLS: Age; gait; impaired cognition,
vision and mobility; medications; failure to call for assistance;
elimination; environmental issues
• Falls occur in all Service Areas!
• Falls occur on all shifts!
• Restraints do not prevent falls!
Patient Safety-Falls
• Fall Prevention:
– All patients are assessed on admission and each shift
– “Risk to Fall” assigned to patients with the following
criteria:
• History of falls
and/or
• Combination of two or more factors: age>70, gait
problems, fatigue/weakness, disorientation/confusion,
medications affecting balance, judgement &/or level of
consciousness
Patient Safety-Falls
• ‘Risk to Fall Plan’
– Confidential ID with “Yellow Armband”
– Frequent monitoring: toileting & ADLs every 2 hours or
as indicated
– Pt & Family Ed Plan - teaching tool
– Environmental Safety precautions
• Keep pathways clear
• Provide assistance with mobility
– Communicate concerns to RN coordinating patient’s care
Patient Safety-Falls
• FALL EVENT
– Notify patient’s nurse immediately
– Assess patient for injury
– Complete an Incident Report
• Report is forwarded to unit manager and Risk Management
• Fall data included on monthly unit report card
• Unit leadership reviews fall data and addresses issues at staff
meetings
Patient Safety-Armband Alerts
• Yellow: Risk to Fall
– Educate patient / family on Safety Tips to prevent falls
– Check physical environment for safety measures
• Pink: Lymphedema Precautions
– Criteria applies to patients with history of Breast
Cancer surgery where axillary nodes removed; dialysis
arm shunt and upper extremity surgery
• Orange: Do Not Resuscitate
– Armband should list “No-Code” or “Limited
Code” with limitations listed
DOCUMENTATION
General Guidelines
• All medical record entries must be done in
black ink & dated & timed
• Errors are corrected by crossing through the
error, writing “error” above the notation &
initialing the error; do not erase or use
correction fluid
• Signature form is to be used by all members
of the interdisciplinary healthcare team to
sign on the chart initially;afterward, use
initials for any chart entry
General Guidelines (Cont.)
• All categories of forms must be completed-do not leave blanks
• Charting by exception:
– A checkmark will be placed in the appropriate
column if patient meets defined assessment
criteria
– If patient does not meet defined assessment
criteria, place an asterisk in the appropriate time
column & document abnormal findings using
bolded letter or narrative note
Nursing Process
• “S” (subjective) & “O” (objective) used by
LPN
• “A” (assessment) documented by
observations & narrative notes; RN function
to use data to identify problem & develop
plan
• “P” (plan) documented on computerized
Interdisciplinary Plan of care; RN function
to coordinate care
Nursing Process (Cont.)
• “I” (intervention) documented on acuity
tool, flow sheets, through narrative notes or
checklists; completed by all who provide
care
• “E” (evaluation) documented at least once
per shift; evaluates progress to goals &
effectiveness of treatment; RN
responsibility
MEDICATION
ADMINISTRATION
Five Rights
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Right patient
Right drug
Right dose
Right time
Right route
RN Responsibilities
• Verifying medication order
• Coordination of administration &
documentation of all routine, PRN & STAT
medications
• Administration of all IV solutions, central
line fluids & piggyback solutions
Respiratory Therapist’s
Responsibilities
• May accept & document telephone/verbal
orders for respiratory/inhaled medications
(e.g., inhaled bronchodilators, sodium
bicarb, etc)
• May administer & document inhaled
medications
Dietitian Responsibilities
• May accept & document verbal orders for
diets or nutritional supplements
• May provide & document oral nutritional
supplements to patient
Pharmacist Responsibilities
• May accept & record telephone or verbal
orders for all medications
• Assesses medications, dosages, interactions,
etc. on patient encounters
• Dispenses medication in accordance with
physician orders
Prior To Administration...
• Medications must be verified by an RN
prior to administration
Medication Scheduling
• First dose of routine doses should be given
within 2 hours of order
• Oral medication should be scheduled to
maximize patient sleeping times
Cultures Before Antibiotics
• When cultures are ordered prior to
antibiotic administration, notify MD if
cultures have not been obtained within 2
hours of written order
• Physician is to specify how to proceed
Labeling Open Medications
• NSS IV flush bottles are intended as one use
only; discard any unused portion after
withdrawing desired amount
• Other medications that are multi-use vials
(e.g., insulin) must be labeled with date &
time opened, as well as initials of individual
who opened the vial
Other Labeling Issues
• If medication is drawn up into a syringe but
there is a delay in administration, the
syringe must be labeled with medication
name, dose, date, time drawn up & initials;
such medications should NOT be left lying
on countertops, etc., but should be secured
appropriately
Other Labeling Issues (Cont.)
• Leave oral medications in wrappers until
ready to administer;it is not acceptable to
put pill into med cup in med drawer
unlabeled
Checks & Balances
• A double check with an RN is required for
dosage calculation for specific drugs:
– heparin
– insulin
– thrombolytics
• Prior to administration, a double check of
the dosage drawn up is required for:
– heparin
– insulin
Checks & Balances (Cont.)
• Those drips that require precise dosing
and/or titration must be administered via an
infusion pump
Insulin Procedures
• Rounding: if the dose is 0.5 units or greater,
round up to the nearest whole number; if the
dose is less than 0.5 units, round down to
the nearest whole number
• Only insulin syringes are to be used for
insulin administration
• Discard insulin vials 4 weeks after opening
• Insulin may be stored at room temperature
after opening
Hypoglycemia
• If a hypoglycemic reaction occurs or the
blood glucose is ≤ < or = 60, shut off insulin
drip (if present) & treat the patient
according to hypoglycemic protocol
Irrigating Solutions
• Label bottles with date & time when opened
• Discard all irrigation solutions 24 hours
after being opened
Controlled Drug Procedures
• All narcotics are kept in controlled drug
storage cabinets or PYXIS
• On non-PYXIS units, the keys to the
controlled drug storage cabinet are to be on
a registered nurse employed by Northside
Hospital at all times
• On PYXIS units, keys to controlled drug
storage cabinets are kept in PYXIS
Controlled Drugs (Cont.)
• In the event of a drug discrepancy (whether
PYXIS or non-PYXIS unit), personnel are
expected to remain on the unit until all
discrepancies are found or accounted for
Waste Procedures For Controlled
Drugs
• There should be no wasted narcotics except
for partial doses
• A controlled drug waste will be witnessed &
“signed” by 2 RNs (either manually on
paper or electronically in PYXIS)
• If an entire dose of an oral or injectable
drug is refused, broken or not used for any
reason, it must be returned to the Pharmacy
by PYXIS or manually by the RN
Waste By Broken Ampules
• In the event of a broken ampule, the
breakage should be witnessed by 2 RNs &
the broken glass returned to pharmacy with
a discrepancy report
Medications From Home
• A patient may not take medications from
home unless the pharmacy does not have
that particular drug
• If the patient presents medications from
home, they should be:
– sent home with the patient’s family, or
– locked up with the patient’s valuables if there is
no one to take them home
Medications From Home (Cont.)
• If indicated & the physician writes the order
that the patient is to take the home meds:
– The medications must be sent to pharmacy for
identification
– The medication must be written on the MAR as
a scheduled medication
– Medication must be kept in Medication Cart on
unit, not at bedside
– Doses must be documented as per usual
Documentation Of Routine Meds
• All routine medications will be charted on the
Routine Medication Administration Record
(MAR)
• Document the EXACT time of administration of
the following:
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Aminoglycosides
Vancomycin
Antiarrhythmics
Theophyllines
Digoxin
Documenting PRN Meds
• All PRN medications will be charted on the
PRN MAR at the time they are administered
• Documentation to include dosage, route
&/or site
• Effectiveness of PRN medication must also
be documented using the effectiveness
codes
Special Documentation
Requirements
• All insulin will be charted on the diabetic
flow sheet as well as the Routine MAR
• All anticoagulants will be charted on the
Routine MAR if they are regularly
scheduled; Coumadin ordered on a daily
basis is recorded on the “one time only”
section of the Routine MAR
Documentation Of Single Dose
Meds
• All one time only medications will be
charted on the Routine MAR in the “one
dose medication” section
• All preop medications will be charted on the
Routine MAR in the “one dose medication”
section
General Med Documentation
• If a generic drug is given, the generic drug
being used must be written above the
ordered medication on the MAR
• Each individual who records medications on
Routine or PRN MAR will also identify
herself/himself on the signature form
• All allergies must be recorded on the
Routine & PRN MAR in addition to the
Master Allergy Sheet
Medications Not Given
• If a med is not given, initial the appropriate
time slot, circle initials & place the
appropriate code for meds not given beside
circled initials
• The physician must be informed if a patient
refuses or misses a dose of medication
Discontinuation Of Meds
• When a scheduled med is discontinued, it
will be stamped or written “D/C” on the
MAR
• When a PRN medication is discontinued, it
will be stamped or written “D/C” on the
MAR
• All D/C’d meds must be verified by an RN
with initials & date
QUESTIONS??
• Feel free to ask your charge nurse, preceptor
or instructor
BEST WISHES!
• We look forward to seeing you soon!