This is my first posting here and I need your thoughts on the following topic.
I have done a lot of research on the topic of medication reconciliation in the ER setting. The Joint Commission says in its FAQ for the 2008 Safety Goals that a separate document in the record is not needed to comply with Safety Goal 8. A list documented in the triage section of your nurses ER intake sheet is in compliance. After speaking with a standards interpreter from TJC, I found out that a photocopy of a patient’s med list, verified, dated, and signed by the triage nurse is acceptable to comply with Safety Goal 8.
TJC has said that in the ER setting a “three tier” system of medication reconciliation can be used. First a “screening reconciliation” is done in triage with just a list of medications. (No dose, frequency, route, or last dose needed here) If the patient’s reason for their visit to the ER involves an ailment that is effected by one of their medications, then a “focused reconciliation” on that particular medication is needed with dosage, frequency, route, and last dose taken. Upon admission to an inpatient unit, a “full medication reconciliation” is completed by the receiving unit.
Despite this information, my hospital mandates a separate form for med recon to be used in my ER adding more paperwork.
I am wondering what other ERs that do not have computerized charting are doing?
first i will say i understand the need to know the pts meds doses etc.but as an er nurse it is not and will not ever be my top priority .i do the best i can with our separate order form for med rec. once the pt is stable.but the pts we see often donot know the doses nor the names. of their meds. a few will come in with a list.if the pt comes in on days or eves and if they know what pharmacy i will call the pharm to confirm the meds.thats harder to do on weekend or holidays.there are also pts who gets meds in mail and don't have documentation of meds and there is no one to call .sometimes the families as bad as the pt and doesn't know. t.hen there are the multitude of drugs/eto h and psych pts.there near impossible to get a med rec on.in our area the psych pt gets meds in dose pack dispenced by psych etc.this is closed after 5pm no where to call if pt doesn't come in with meds or have a list.i always document all the efforts i take to get med rec pt family pharmacy md calls etc.once the pt is admitted family md comes in pharmacy open in the am etc i feel the floor nurse has a better oppourtunity to reconfirm med list .as a matter of fact it is my hospitals policy that the floor does it .and beyond that since med rec form is consider order sheet md has to read and either cont or d/c med .we for most part don't get md orders for the floors .we only have to get orders on icu admit.this is all my views on this as er nurse.while i appreciate floor nurses are busy too .the med rec is not completed wrong or incomplete because er nurse is "lazy or didnot attempt to do it".i actually had a floor nurse call me and yell at me because med rec form was not complete yet i did everything poss to complete it and documented my attempts.pt was senile did not know meds no list couldn't state pharmacy.husband same .these people actually lived at home.on nights so couldn't call md office and left message for daughter to see if she knew.so the floor rn had to do it.oh well.
Last edit by nuangel1 on Sep 3, '08
: Reason: spelling