Charting meds while pt is out on pass

Bird2 · Apr 15, 2006

What is the proper way to chart meds on a medication sheet when a patient is on a pass/"Therapeutic assignment" (and the pt has been given the meds to take while they're out)?
I've seen:
1) the space left completely blank (not good because later how would you know whether or not the pt was gone or someone didn't give/forgot to chart the med)
2) the letters "TA" & the time written with a circle around it -- with and without the nurses' initials (but then it kinda looks like it was withheld due to the circling of it)
3) the letters "TA" & the time written with NO circle around it -- with and without the nurses' initial
4) just the letters "TA" in the box -- no time or nurses' initials
5) "TA" written at the top of the column with a line drawn down through all the boxes for that shift
Does anyone know the proper way to do it?

It would depend on your facilities policy but we initial then circle our initials. Then on the back of the MAR chart "med got given d/t pt being out of facility" or meds sent with pt. Then we chart in the nurses notes what time they left, the condition they left in, why the meds or treatment s were not completed, if they received education on the meds that they would be taking per self and what time they returned.

Ruthiegal · Apr 15, 2006

What is the proper way to chart meds on a medication sheet when a patient is on a pass/"Therapeutic assignment" (and the pt has been given the meds to take while they're out)?
I've seen:
1) the space left completely blank (not good because later how would you know whether or not the pt was gone or someone didn't give/forgot to chart the med)
2) the letters "TA" & the time written with a circle around it -- with and without the nurses' initials (but then it kinda looks like it was withheld due to the circling of it)
3) the letters "TA" & the time written with NO circle around it -- with and without the nurses' initial
4) just the letters "TA" in the box -- no time or nurses' initials
5) "TA" written at the top of the column with a line drawn down through all the boxes for that shift
Does anyone know the proper way to do it?

Initial and Circle the medications you are sending with the patient, and chart on the back of the MAR that they were sent with the Pt. and the pt's responsible party. Also chart what time they left, what condition they were in when they left, who they left with, and that medications were sent along with the pt, with instructions on dispensing to the responible party.

Upon the patients return, you would then chart the time returned, who they were with when returning, condition, and in most cases the responsible party with the pt. can tell you if all the meds were taken or not and you can chart what they they tell you in quotes.

Of course if your facility has a policy that differs from this you would have to follow that policy.

Have a wonderful day! :balloons:

Mydnightnurse

Daytonite, BSN, RN · Apr 15, 2006

Boy! Have you opened a can of worms! You should not assume that anything anyone answers you about this is correct for your facility to be on the safe side.

First of all, your facility should have a policy or instructions on how to handle this. If not, bring it to the attention of the DON and ask that a policy be written.

Second, the pharmacy service or computer service who prints your MARs should have a list of acceptable abbreviations you are supposed to use on the MARs as well as instructions on documenting on the MARs. It would be a good idea to try to find this document because this kind of situation may be addressed in it.

This is how we handled patients who went out on pass at the last facility I worked. The patient, or whoever was responsible for the patient was given all the medications that would be needed for the exact amount of time the patient was going to be out along with adminstration instructions. The pharmacy supplied us with special envelopes for these medications that had blanks to fill in with regard to the administration instructions. We used the letter "P" on the MAR in the space for the medication which meant "out on pass". On the back of the MAR an entry was made for each medication. The date, time and number of pills sent out with the patient was documented and whom the pills were given to, and then signed by the nurse. Upon return, another nurse made a notation of the date, time and the number of any pills that were returned to us when the patient came back. If doses were missed, we were supposed to get a reason from the caregiver and make a statement on the back of the MAR as to which doses were skipped and why in the words of the caregiver.

branco · Apr 15, 2006

Boy! Have you opened a can of worms! You should not assume that anything anyone answers you about this is correct for your facility to be on the safe side.
First of all, your facility should have a policy or instructions on how to handle this. If not, bring it to the attention of the DON and ask that a policy be written.
Second, the pharmacy service or computer service who prints your MARs should have a list of acceptable abbreviations you are supposed to use on the MARs as well as instructions on documenting on the MARs. It would be a good idea to try to find this document because this kind of situation may be addressed in it.

We don't have a policy on it. I am going to approach the DON this week.

To me, seeing the circling implies "withheld" and that it wasn't given -- which makes it confusing when trying to count up the dosages for charges when doing the pharmacy billing list (esp. when doing a pt's chart who was there for several months).

Thanks for the above replies....and any more suggestions are appreciated!

Pepper The Cat, BSN, RN · Apr 16, 2006

We just put OOP (out on pass) and our initials.

barbyann · Apr 16, 2006

I have always gone under the assumption that by circling something on the kardex it signals the reviewer/reader that something out of the norm happened and the details could be found noted on the back of the kardex. I circle meds and intial/no intial for many different reasons (refusals, OOP, late in receiving, vomited meds, not available meds, NPO) In other words, there are many different reasons a patient may not get their meds from the nurse. When an out on pass pt returns I write a brief note that includes a quoted statement from the patient ("Yes, I took all my medication while out") and their condition upon return. I agree this should be part of policy but it seems to be overlook in many facilities.