First-Pass Medication Note

[fady]

Hi all, I have a question for my understanding. I have been asked to implement first pass medication note for all nurses in my unit as a charge nurse but there has been no clear guidelines. Do you write a note for every medication provided inpatient or is it just for medications that the client is using for the first time ? Any guidance in this regard would be appreciated.

[JKL33]

Need more info. What is supposedly the purpose of this note? I haven't heard nurses refer to "first med pass note" over the years. 

[fady]

The administration is asking to document every time a new medication is being started for the client. Is it a routine practice?

[chare]

At both my current and previous facilities this was an expectation for all newly prescribed medication, in both acute and intensive care.

Epic refers to this as first dose education.

[kbrn2002, ADN, RN]

While I hadn't heard it called that it's standard practice where I work. The charting software flags a new medication order as a first-time dose and it is required to give that med by itself and at least 1 hour apart from other meds. 

[ArrowRN, BSN, RN]

Sounds like a nightmare if you have to write a note for each med....I would do a general note something like Patient has been given education on use and purpose of each medication and has been made aware or potential side effects. Hand out given for new med education, patient able to restate why medication is taken and verbalizes understanding....if you using EPIC EMR, save you save it as a smart note. 
When it comes down to it what your leaders really wants is good HCAPS surveys...get with your clinical leader and nurse educator to find out what questions patients are being asked related to medications during these surveys. That will be your guide. Create a guideline.  Of course makes no difference if a note is created and it's not being actually done with the patient. When I was staff nurse I created a flash card project that was simple to understand to give out to patients when they had a new meds it increased our HCAPS survey scores on our unit.