Vent: Admits and discharges

caroladybelle, BSN, RN · May 8, 2007

JACHO currently is pouncing on the admission home, and DC med issue. I am surprised that your risk management department hasn't done something yet.

Most places are now requiring that the home med issue be covered in the ER, and that the admission orders address them. The first nurse that sees the patient makes a list on a sheet separate from admit data (or if on computer, prints up separately). That is put in the admit orders with check marks to continue or not continue, a place to sign and that serves as the order sheet.

Each day (usually on nights) an updated sheet prints with the meds the patient is on and used at home. It is placed at the front of the orders so that the MD can review if s/he wishes. If the patient is DC'd , they check what they want continued at DC.

Of course, many are still to lazy to do so.....but this way they have no fall back excuse of "Well I didn't know that the consult ordered that", or the "I couldn't find an uptodate list".

General E. Speaking, RN, RN · May 8, 2007

Same problems. Very frustrating. It is annoying when the home med sheet is not even addressed. It is even more annoying to have to put a note on the chart 2 days later stating "Doctor X, please address home med sheet" Then many times they mindlessly check to con't all of them when some of them are not appropriate. For example the patient is put on Protonix by the ER doc and the admitting doc checks to con't their home med of Nexium. Or worse, they are on Morphine IV Q2 hrs and they check to con't their home narcotics, sleeping pills, etc.

Our ER sometimes does the home med sheet, but many times they just list the name- no times or dosages. families get very frustrated because they shlep the meds in a baggie and think they are recorded properly so they take them home.

Hate, hate, hate "D/C home" orders. I think they should be required to address the home meds, activity, diet and follow-up. We even have a place on our home med sheet that they can check if they want them con't at home. Most don't.

oldiebutgoodie, RN · May 8, 2007

Same problems. Very frustrating. ... Then many times they mindlessly check to con't all of them when some of them are not appropriate.

Yes! The patient I was writing about was taking Viagra, and the MD checked the box to continue Viagra Q HS. Pharmacy called me very worried about the order, wondering if pt had pulmonary hypertension. I assured them he didn't, and they (thankfully) DC'd the order.

AAAAAAAAAACK!

Oldiebutgoodie

General E. Speaking, RN, RN · May 8, 2007

Yes! The patient I was writing about was taking Viagra, and the MD checked the box to continue Viagra Q HS. Pharmacy called me very worried about the order, wondering if pt had pulmonary hypertension. I assured them he didn't, and they (thankfully) DC'd the order.
AAAAAAAAAACK!
Oldiebutgoodie

hehe, I had the same situation. Doc checked to con't Viagra Qhs prn. I scanned it to pharmacy and got a call from the pharmacist who was laughing hysterically. She told me she would not put it the MAR.

morte, LPN, LVN · May 8, 2007

Hello, all,
Do your hospitals have any better protocols for admit and discharge orders? I feel like I'm doing a lot of the MD's work.
grumble grumble
Oldiebutgoodie

you are, and untill there is a consequence to the doc (like they have to come back in to fix the order) you will continue to......good luck

wooh, BSN, RN · May 8, 2007

hehe, I had the same situation. Doc checked to con't Viagra Qhs prn. I scanned it to pharmacy and got a call from the pharmacist who was laughing hysterically. She told me she would not put it the MAR.

Now our policy states that you have to have a prn reason. Was the viagra prn pain, nausea, agitation? :devil:

Roy Fokker, BSN, RN · May 8, 2007

I feel like I'm doing a lot of the MD's work.
grumble grumble
Oldiebutgoodie

I share your pain.

Some of our docs (even some of our old surgeons) are pretty good about it (a colleague who routinely pestered this surgeon about the med-rec sheet now has him hounding her out to present the sheet so he can sign it at discharge! :chuckle)

But many of our docs are absolutely useless about it. Some of them are so horrible that they check "continue" on ALL of the meds (even the ones requiring IV access for example :uhoh3: :trout::angryfire:angryfire). They don't even bother to read the list - because they know that we'll "catch" the mistake and "cajole" them to fix it.

Very frustrating because it ties up beds/staff on the floor needlessly while Doc is being chased down to get clarrifications.

But I guess it's nothing compared to the surgeon who leaves the post-op PCA sheet blank and signs "per RN choice" on the bottom for what needs to be ordered :uhoh3:

Sometimes I think that we as nurses pamper them up the butt and they become this complacent and lax....

cheers,

INtoFL_RN · May 8, 2007

Our hospital is putting forth a pretty good effort to address this, and thankfully our docs are cooperating well. It's a JCAHO thing, which ultimately leads to a reimbursement thing. Since we are a small community-based hospital, they take these types of things very seriously.

On admission, a pharmacist is responsible for obtaining from the patient their list of home medications and verifying the dosages. Then the attending MD is to review those meds and individually circle whether or not to continue or DC within 24 hrs of admission. Circling all is not acceptable! PRNs MUST have an indication listed. We are not allowed to say "one to two tablets" either, it has to be written as "12 to 25 mg PRN nausea" or whatever.

On discharge (or transfer to another unit), the MD tells the secretary to print up a form that lists all the patients' current meds. They must individually circle whether or not to continue each med. The original home medication form from admission is kept in the front of the chart, so MDs should be referring to that as well when writing DC orders.

Since I work in a cardiac unit, most of our patients can be DC'd with a standard form based on diagnosis that states their activity restrictions, diet, etc. I have rarely had to call docs back to clarify some sort of discharge issue. I'm really glad we have this system in place. We do enough hand-holding and secretary work for these docs sometimes!

purple1953reading · May 9, 2007

We, too,had problems with drs. who just are too lazy to review, let alone write for the home meds. They made it a policy that the physcan couldnot write CONTINUE HOME MEDS, but must list each and every med, dose, diag. etc. and they must be in his own hand writing on the admit note. BUT

I work as House Supervisor,and once I went on and the pharmacist had prepared a MS drip, by adding the med to a bag of 500ml Saline, and it was not locked in anyway just hung openly in a room on a pump. I could NOT believe my eyes. Called him at home, and he said IT was for comfort to die anyway, and that it would cost so much to use PCA, and she couldn't proably access anyway. I reminded him we could set continuous drip with PCA. Anyway, I told them to take it down, and waste it with two rns signing the waste, and get PCA orders and hand one. But the patient expired, as expected, and the pharmacist thought I was wrong. DON eventually took care of him. Physcians will let us do as much work as we will for them.

ROSYJO11 · May 14, 2007

Our doctors hand write the patient's medication on a special sheet when they are admitted. Anything ceased during pt stay is crossed off that sheet by the doctor.

When patient goes home they are given a discharge form and their medications are written on that by the nurses (copying the orders off the med chart and double checked with another nurse). It gives drug, dose, frequency. It is not a script but a handy checklist for them when they go home of what they NOW take and how much and how often.

Occasionally the doctors will write self medicate on the med chart for those short stay surgical patients and the discharge form we dont fill in the med part.

Doctors often write home or discharge, will write in a follow up time period if the doctor wants one.

Keep in mind though that I am talking about a private hospital with specialist consultants. The GP's only get involved on occasion but their discharge orders arent much different , they wont write for a follow up appt.

Jo

chuck1234 · May 14, 2007

Hello, all,
I am just so aggravated about admits and discharges.
At our hospital, even if the doc has written orders, we often have to call him/her back because they didn't:
1. Reconcile the home meds
2. They did reconcile the home meds except for the last page
3. Didn't order certain things--labs, test, tele, etc...
This weekend, pt came in with Hx of heart probs. I suggested pt be put on tele. Doc says, "Oh. Okay". Pt has 2nd degree heart block, type 1. I call doc to report, ask if he wants cardio consult. "Oh, I guess so". Geez.
On discharge, doc often sneaks in and writes in orders, "DC home". Of course, he/she has not looked at the home meds to see if pt should continue them. So, I have to call them back to go over the home meds, which, most of the time, have some med that the pt SHOULD NOT be taking. Several times, when I call to discuss home meds, the doc has said, "Oh my God. NO, they can't be taking that". We have the home meds on the computer, and doc can easily look at them, but they don't.
Do your hospitals have any better protocols for admit and discharge orders? I feel like I'm doing a lot of the MD's work.
grumble grumble
Oldiebutgoodie

In school, the instructor always said that nurses should follow the M.D. order....But once you have experience in the field, you feel like nurses are the doctors....

Good luck...and hang in there...

Have a Happy Mother's Day...