Med Reconciliation in the ER

[Rickbos]

Hi

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?

[mpccrn, BSN, RN]

i've often found that ER med reconciliations are not accurate. sometimes i wonder if they even read what they are writing down as i often find some meds listed several times with different doses. at our hospital we have an admission nurse that does med reconciliations as her first priority, followed by doing admission assessments if there is time left over. seems to me that there is an importance placed on med reconcilliations of late...perhaps a nurse dedicated to just that might be in order........but no thanks....would never want that job.

[Larry77, RN]

Our facility has gone crazy over med rec...we now have 24 hr pharmacy tech's (sometimes pharmacists) doing med rec's on every patient that comes through the door. If they are not admitted I believe they do a quicker version but on admits the list is completed with last time of each med etc. We even made an office for pharmacy.

We do have a quick list of meds from triage on the chart as well. I also work some agency jobs and have not seen other facilities do such a thorough job. Most of the time it's just a separate sheet that the nurses are supposed to fill out but most just simply make a list of meds taken without doses (no time) because they took away the spot on the chart for meds from traige.

BTW...welcome to Allnurses...be careful you will probably become addicted and have to check the site daily :)

[stayseerrn]

Computerized charting has been both a godsend and a curse for med rec. It is a god send because most computer charting systems retain info from previous visits and d/c rx from the most recent ER visit. However, it is also you worst nightmare. Some computerized systems are systemwide. Which sounds great until you try to figure out which dose of coumadin the patient is on now after the doctor has been spending the last 6 months adjusting it. Computerized charting helps keep a list of meds a patient has been taking, but it doesn't easily filter out what are the current meds and dosages. My favorite stand-by is to have the patient bring all of their current medications with them. That way I can input the data based on their current intake and not have to sort through multiple computer screens to figure out what they are on right now. But unfortunately, I am finiding out that it is the ER who is having to do most of the med rec. In fact, I have had residents tell me that they cannot proceed with writing the patient's admit orders until I get a complete list of their medications. This of course, contributes to the pt being boarded in the ER longer. But, that is a whole different talk show. Net result, best bet is to have the pt bring their medication bottles with them.

[farmerRN]

In the ER I work at...every patient has to have a full med rec filled out. It is a big pain in the butt. Even though we have linkage with the clinics...alot of meds do not have accurate dosages or old meds that are not updated by the clinics. The hospital is not allowed to change them. It is a bigger pain in the butt when we have nursing home patients with 3 pages of meds...usually the med rec forms are finished long after we send the nursing home patient back home. In general...its a pain in the butt...and gawd forbid if we admit a patient...we do not find out their daily dose of lasix for the admitting unit!!!!!!

[Jennifer, RN]

We are required to enter all patients current meds into the computer when triaged, including dose, route, frequency, or document that they are not taking any meds or that their meds are unknown. Upon admission, the computer automatically prints up a med reconciliation form from the ER chart. Once entered correctly, if the patient returns at a later date to the ER, there is a record of their meds from their old chart, and, after checking to insure that the meds are still accurate, we can easily just click and enter them. I haven't found it to be too big of a hassle.

[Firefighter26]

In my facility Med Rec is held up somewhere between the 10 Commandments and the Declaration of Independence....and for the life of all of us we can't figure out why it needs to be charted in it's entirety 3 (three!) times.

And if the floor doesn't get all three copies in all 3 different formats you can bet they're going to raise hell about it.

Go figure. It's time taken away from pt care.

[nuangel1, BSN, RN]

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.

[mmutk, BSN, RN, EMT-I]

As an ER Nurse I would agree that inital med recs are not completely up to date although obtained in the ER, secondary to high acuity and stress on both families, patients, and nurses.

[al7139, ASN, RN]

Hi,

We now have computerized charting, but before we switched the pt was required to have a "hard copy" med rec done in the ED. We are lucky that we have an "admissions nurse" in the ED who tries to get to all the admissions to do the med rec and other admission ppwk. She does her best to be accurate with the med rec, but I still did a med rec confirmation with the pt on arrival to the floor (and still do!). The reason is that often the ED nurses may document what meds the pt is on, but do not list when each med was last taken (so VERY important in preventing an accidental OD!!!!!!). Also, the pt may have not arrived to the hospital with their list of meds (or the meds themselves), so the dose may not be listed, or updated. I have found through experience that it is important to do the checks and double checks to ensure accuracy and prevent errors. I like when the pt shows up to my unit with their actual meds, because it is a good way to tell if 1. They are compliant (look at when the Rx was filled vs how many are left). 2. They are taking the right dose. and 3. If the med is documented correctly. I then send the meds home with the spouse or family member, and can tell what meds I need to give, and what to hold based on what they have taken that day. I never take a med rec at face value until I have confirmed it for myself (sorry, I know we are all thorough, but we are also human and can make mistakes).

I also make sure to specifically ask for OTC/herbal meds since most people don't have those on their lists. Also I specifically ask male pts about Erectile Dysfunction meds, you would be surprised how many do not include them on their med list because they are embarrassed or shy about them, but so very important to know, especially on a heart unit!

Amy

[crb613, BSN, RN]

We are required in triage to enter their meds....dose, route, & frequency. If they do not take any meds that must be documented as well. Our computer system stores this info. Then with any visit these meds automatically show up, & would have to be verified each time. The only problem is when whoever is in triage does not double check to be sure all of this is still correct......& just enters this old info as current.

If the pt is admitted we then have to hand write a med rec. with all the above, with time of last dose, pharmacy used, & if the med info was taken from pt bottles, pt/family recall, pt list, MAR from other facility. I always go in & go over each med with the pt/family to be sure they are correct....sometimes this is not possible if they can't communicate or have no family around.

The ER doctor then has to sign & check all meds as either continue or dc. If we could just print out the triage med rec it would save soooo much time!