Med Recs

  1. Hey everyone, gots a question for you. Anybody familiar with having to provide a medication reconciliation for patients being discharged from your EDs? I was just informed by my nurse manager that we have to devise a system to provide patients with a med rec that has all of their meds on it not just what is being added or changed. This is going to be time consuming as all hell if I have to write or type out every medication and dosage for every patient that comes through our ER as we have no unit secretary, just 2 RNs and a doc. This came to us via. a JCAHO representative.

    Any and all advice or ideas are more than welcome.
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    About budger1983

    Joined: Apr '05; Posts: 11; Likes: 4
    Specialty: RN CEN

    20 Comments

  3. by   walk6miles
    We have that here in Florida (Central) - it is put into the computer initially by the ER nurses - when we admit the patient, they look over the Med Rec and sign it. Surprisingly, there are very few mistakes in meds showing up on these sheets.
  4. by   canoehead
    We've been told that eventually we'll have to type in all the meds a patient takes when we enter info in the computer, then update them at each visit.
  5. by   TRAMA1RN
    All hospitals are doing this it is a JCOH requirement. It is time consuming especially when our ED sees 60,000 visits annually are we are NOT computerized. It really is in the best interest of the patient though, making sure the patient is on the correct meds and no duplicates. In this day and age when patients see several different MD.'s this is a good comprehensive way to manage your patient. Time consuming yes, but really puts the patient first and until we can figure out a way for all our patients to take responisibilty for their healthcare needs, it is the best system for now.
  6. by   mamalle
    we hav computer charting so it is preprinted. The triage nurse has to put them all in. our doctors are not compliant with it upon discharge though. Upon admission we go over it with the admitting doctor and sign it at the bottom.
  7. by   BBFRN
    Quote from evilnightwitch
    All hospitals are doing this it is a JCOH requirement. It is time consuming especially when our ED sees 60,000 visits annually are we are NOT computerized. It really is in the best interest of the patient though, making sure the patient is on the correct meds and no duplicates. In this day and age when patients see several different MD.'s this is a good comprehensive way to manage your patient. Time consuming yes, but really puts the patient first and until we can figure out a way for all our patients to take responisibilty for their healthcare needs, it is the best system for now.
    I can't imagine doing this without being computerized- ugh. One good thing about computerized med recs is that if the patient returns to the hospital, you can pull up their last med list and take it from there.
  8. by   mamalle
    even though Im not a huge fan of our new computer charting ( medhost) that is a plus when you can merge the info from the last visit. some of our patients are on 3 pages of meds..
  9. by   cappuccino
    Med recs are a big help. Especially post-op because the printed forms can be checked off quickly by the mds. We all know that if they had to write out the med orders, something would be missing. So this is a good way to renew meds and order meds. Our ER usually writes out a med rec form and has the attending or the ER doctor check it off..............
  10. by   kmoonshine
    The concept of med recs is a good idea, but it can be time consuming.

    I find the biggest problem is the patient not knowing what meds they take. "Um, I take something for my blood pressure...don't know the name"; I'm diabetic, but I take those pills...". To me, this is by far the biggest problem with the med rec process.
  11. by   Larry77
    Ours are really easy if their PCP is located in the clinics associated with our hospital, but if the patient is a Kaiser patient or in a couple outside clinics there is no records in the computer and we have to hand write every med rec form.
  12. by   Jennifer, RN
    We do this too, but personally I think it just takes more responsibility from the doctor and puts it on the nurses. Pretty soon, hospitals will only have nurses, no doctors, transport, lab, registratioin, etc....
  13. by   rn46
    The last E.R. I worked in we had to do them on every pt. that came in. It was even reported to my travel Co. because I hadn't done one by the time the Dr. came into evaluate the pt. for possible admission. I didn't even know the pt. was going to be admitted.
    rn46
  14. by   grammyr
    We do them on everybody who has home meds and if they get a RX before they leave. Kinda sucks to do them on headaches,toothaches,etc but we have pretty much gotten into the habit. We use paper charting so it takes a while for the patients who have a lot of meds.

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