Medication reconciliation/orders

[KelRN215, BSN, RN]

I am a home health case manager. When we admit or recertify a patient, we reconcile their medications, update on the 485 and then send to the MD for signature. Many of our patients come from one oncology clinic and a few of the MDs refuse to sign the 485 without first crossing out all of the medications. I received a 485 today with all the doses crossed out and a note on it that said "Medication dose, route and frequency should be as specified in original order. I am unable to verify if the orders were transcribed correctly." Um, WHAT? You're the patient's prescribing MD and you see her once every 3 weeks- how are you "unable to verify" the doses? It's called medication reconciliation! Look at what you ordered and make sure it's up to date! And it's also not true that the dose and/or frequency are always the same as in the original order as doses for meds change all the time and they don't always send us a new order. That's why we send the updated list for signature with the new 485.

Does anyone else deal with anything like this?

[ctrn3478]

unfortunately it sounds like youll need to call to verify which meds are even incorrectly written that note sounds too vague and confusing..where did you get the last med list, the last 485 or an updated list in the file? whenever i get confused i just call and request they fax over their most recent list asap

[salvadordolly]

we have a doctor that does this all the time. he won't sign off on meds not prescribed by him. he'll write, "can't verify these meds". we have to fax him the original orders from the cardiologist, nephrologist, etc. so that he will sign the 485. complete PIA.

[KelRN215, BSN, RN]

The thing is, these are meds that ARE prescribed by the MD who signs the 485. Most of their meds are directly related to their cancer/treatment/side effects and are things like zofran, bactrim, colace, miralax, zantac, steroids, etc. If I call the clinic and ask them to fax the most up-to-date medication list, even the clinic nurses will say "we can't promise it's right." They cross out ALL the meds regardless of whether they're right or not and fax the 485 back signed but with all the meds crossed out. I'm not sure what the right thing to do in these situations is. I have considered calling the clinic's Case Manager and saying that we can't accept the 485s the way they are sent back to us, but I don't know if I would get anywhere doing that.

[salvadordolly]

How bizarre! How could they not be sure about what they've prescribed? On a very few occasions, I have called an Office Manager and explained that the clients services would have to stop if they couldn't cooperate with the 485 process. I have occasionally had clients switch doctors to one that seems to cooperate better. Would the primary doctor sign rather than the oncologist?

[KelRN215, BSN, RN]

Nope, the primaries almost always refuse to sign because the reason we are in there is because of the cancer diagnosis. Truthfully, the oncologist SHOULD be the one signing the orders... they see the patients all the time and the primary may not see them at all during the entire duration of treatment. People who have children on chemo generally don't want to bring them to the pediatrician's office to sit in the waiting room with a bunch of sick kids when their kid is immunocompromised when they see a doctor at the very least every few weeks in the oncology clinic. We have written chemotherapy orders that we get when we are to administer chemo and we're not actually administering any of the other medications that the MD's cross off on the 485 (other than the occasional injection, but we have written orders for those too) but we still need the current/updated orders in order to properly instruct the patient if they have questions on their meds.

[salvadordolly]

We've had a few problems like this, we will attach a note to the 485 stating that MD doesn't want this or that on the 485 for this or that reason. We will document the conversation with the MD/nurse/OM on this paper. Some doctors are afraid by signing a 485 that they are giving orders.

[LadyT618, MSN, APRN, NP]

Sounds like the MD needs to be educated on the requirements of the 485 and what goes on it.The meds listed are not going to necessarily be prescribed by him/her; it represents ALL the meds being taken by this patient. Hell, many docs don't know their patient is taking herbal meds, but they need to be on the list because they're taking them and it may interfere with prescription meds. Perhaps you can make a field trip to this doc to provide this much needed education. :-)