Our hospital is not online with computer charting yet, we go live here in a month or so. Right now, we have a Med Rec form that has spaces for about 20 meds, whether the doc wants them continued, dc'd, or the dose modified. At the top is a place for allergies of all kinds, rx, latex, foods, etc.
The nurse gets the orders from the physician to continue/hold/ or modify whatever meds he wants, and yes that includes going thru a 3-4 page NH MAR. Sorry, JCAHO is firm on this one, it is not going to go away. And weren't we doing this anyway, without a formalized method to document it??? At least I hope we were doing it. I've called family members, pharmacies, nursing homes ( if they forget their 3 page MAR in the transfer papers), whatever is needed to get those current meds. That form then with the meds is taken as a phone order and faxed to pharmacy to get your admit meds. Doc has to co-sign his phone order within 24 hrs, just like any other telephone order. I don't see unit secretaries doing that... too much clinical info for them. I guess we're gonna have to bite the bullet on this one.