Transcript Med Profile Tab – “One Source of Truth”

Med Profile Tab – “One Source of Truth”
ACCESSING THE “One Source of Truth”
Physicians: through “Admission or Post-Op
Order Sets” or Placing a “Medication
Reconciliation Order”
Nurses: Medication Reconciliation PowerForm
through Task List or Ad Hoc Charting
Pharmacists: Medication Reconciliation
PowerForm through Multi-Patient Task List
(MPTL) or ad hoc charting
READING THE MED PROFILE TAB
Medication(s) Being Given
These are inpatient meds that have been
ordered for the patient. The current and past
folders determine if the med is active (current
folder) or discontinued (past folder).
Prescription(s)/Home Medications
These are outpatient meds (denoted by an
Hx) that have been documented by the
admitting physician. The current and past
folders determine if the med is an active
(current folder) or discontinued home
medication (past folder).
Adding a Home Medication to the Med Profile
1. Right click on the green divider labeled “Prescriptions/Home Medications”
To cancel a Home Medication
from the Med Profile
3. Click on “Product” radio button (top left)
1. Right click on the prescription
or home medication you want
to delete.
4. Type in name of drug
2. Click on “Cancel/DC”
5. Double click on drug or click “Select” to populate medication details
3. Review order/cancellation
screen
2. Click on Add Medication by Hx
6. Continue steps 4-5 until all home meds are added and click on “Sign Orders”
“Sign Orders” refers only to populating the Med Profile Tab – This does
NOT order the medication
4. Click “Sign”
Roles and Responsibilities for Medication
Reconciliation
ADMISSION
1.
Physicians document home medications in Med
Profile Tab by placing a “Medication
Reconciliation” order or through an Admission or
Post-OP Order Set; if home meds already there,
confirm accuracy of home med list
2.
Nurses verify home medications with patient,
add any new information to the med profile,
reconcile home medications with inpatient orders
and document all information above in the
Nursing – Medication Reconciliation PowerForm
3.
Pharmacists reconcile home medications with
inpatient orders and document in the Pharmacy
– Medication Reconciliation PowerForm
Medication
Reconciliation
Note: For ICU patients, ICU pharmacists will perform
medication reconciliation – Steps 2 and 3.
TRANSFER
1.
All Physicians place a “medication
reconciliation order” at transfer. This order
signifies that the physician has reviewed the
current medications and reconciled with patient’s
home medication list in Med Profile Tab.
2.
In ICU, ICU Pharmacists reconcile home
medications with current medications upon
transfer in and transfer out of the ICU
DISCHARGE
1.
Physicians place a “Discharge – Medication
Reconciliation Order” and update the patient’s
home medication list prior to discharge
2.
Physicians can insert home medications from
the Med Profile Tab into the Discharge Summary
and Discharge Instructions (Please confirm
medication list is translated into patient-friendly
language i.e., change BID to 2 times a day)
3.
Physicians communicate the most current
medication list to next care provider and give
patient updated home medication list in patient
friendly language
4.
Nurses complete discharge note and verify
updated home med list has been given to patient
and is consistent with discharge instructions
National Patient Safety Goal #8:
To accurately and completely
reconcile medications across
the continuum of care.