Transcript Betty Smith poster

Betty Smith
Changes to home meds
written as new
medication orders
NKDA
Sept 27/07
1500
Admit to Dr. Black - pneumonia
CBC diff, Cr, lytes
DAT and AAT
O2 sats >91%
Daily INR and daily coumadin orders
Increase Lasix to 40 mg po daily
Levaquin 500 mg po daily
Prednisone 50 mg po daily x3 days
New medication
orders
Instruction to see Medication
Reconciliation and Physician’s
Orders form for home
medication orders
See Med Rec Form for orders
Dr. Black
Sept 28/07
Tylenol 650 mg po bid prn
TO Dr. Black/Pharmacist Jan
Discrepancies from ‘Late
Entry’’ discussed with
physician and new orders
written.
Nursing
Instructions
Physician
Instructions
Check ‘No home medications’
box if appropriate.
Indicate time and date history
obtained.
Betty Smith
Indicate ALL sources of
information used to obtain
BPMH. Label and attach
copies of information to
prevent duplication of effort
for next care provider.
Complete the BPMH
Always talk to the patient
and/or caregiver. Do not
assume that any list is
accurate. Note dates on any
list supplied. Verify
information with at least 2
sources if possible (more if
required).
Sign immediately below your
last entry.
A late entry to the BPMH can
be made immediately below
current information. Sign and
date.
Record self prescribed
medications (cold remedies,
herbals, vitamins) in this
section. These will not be
supplied in hospital unless
specifically ordered by
physician.
Document important
information for clarification of
medications as needed.
Review and verify home
medication history with
patient. Update BPMH as
needed to ensure
accurate list.
Sept 27, 2007
Indicate whether a home
medication will be
continued, discontinued or
changed in the hospital by
initialing the appropriate
box.
1030
x
x
ASA
Lipitor
Sotalol
Furosemide
Warfarin
Altace
Lactulose
Zopliclone
x
St Michael’s
81mg
20mg
80mg
20mg
5mg
5mg
15ml
3.75mg
472-4520
po
po
po
po
po
po
po
po
daily
daily
daily
daily
daily
daily
qhs prn
qhs prn
B
B
B
B
B
BP high-dose increase
Daily INR & orders
B
B
B
Document the reason for
discontinuing or changing
a home medication to
improve communication to
future care providers
Draw a line from the last
medication ordered to the
physician signature box to
prevent further
medications from being
ordered at a later time.
Nurse Efficient --------------------------------------------------Late Entry
Tylenol
650mg po
bid prn
Jan Pharmacists --------------------------Sept 28,07
Sign and date the
physician's orders
Multivitamin 1 tab per day
Dr. Black
Sept 27, 2007
B
1500 hrs
Nystatin Suspension prescribed Sept 22-29 but discontinued by physician Sept 25 once
problem resolved. Lactulose Rx 15 ml po bid but pt only takes 15 ml qhs prn. Tylenol for mobility 5-6 x/week
Write orders for
changes in home
medications and orders
for NEW medications
on the usual
‘Physician's Orders’
form. Note to ‘follow
Med Rec orders’