際際滷

際際滷Share a Scribd company logo

Electronic Medication Reconciliation

L
learfield

This document discusses electronic medication reconciliation at Phelps County Regional Medical Center. It provides screenshots of the electronic medication reconciliation process when a patient presents to the emergency department, is admitted to the hospital floor, is transferred within the hospital, and at discharge. It notes the challenges of medication reconciliation including a patient's ability to recall their medications, language barriers, stress of transitions of care, and ensuring accurate and complete medication histories. It also discusses a new challenge of transitioning to an electronic health record for medication reconciliation and the complexity and compliance needed to use the electronic system efficiently.

1 of 14
Downloaded 13 times
Electronic Medication Reconciliation Phelps County Regional Medical Center Karen Clover, BSN, RN Pam Karr, MSN, RN-BC
Patients Presentation Patient presents to the ED Nurse obtains current medication list Available for viewing by ED physician
Screen shot of what nurses review on admission
Electronic Medication Reconciliation
Screen shot of ED med list
Patient admitted to facility Patient arrives to floor Nurse reviews previous med list and confirms accuracy
Physician Reconciliation Screen shot
Patient transferred within facility Screen shot of physicians med rec with transfer
Discharge Physician screen shot of d/c med rec
Phelps County Regional Medical Center Discharge Medication List / Discharge instructions Patient Name: Patient Joe Report Status: Signed Account Number: Report Number: 0525-0024 Attending Physician: PLEASE KEEP THIS LIST BRING IT WITH YOU IF/WHEN YOU MUST RETURN TO T ***NOTE: Patients and families are reminded to discard old lists and to update any records with all medication p Discharge Instructions ALLERGIES Coded Allergies: IVP Dye (Severe, ANAPHYLAXIS 04/01/11) Penicillin's (05/17/11) PRESCRIPTIONS Continue taking these medications: Norvasc (Amlodipine Besylate) 10 MG TAB 10 MILLIGRAM ORAL Daily Prilosec (Omeprazole) 20 MG CAPDR 20 MILLIGRAM ORAL Daily Synthroid (Levothyroxine Sodium) 75 MCG TAB 75 MICROGRAM ORAL Daily Caltrate-600 With Vit D Tab (Calcium Carb/Vit D3/Minerals) 1 TAB TABLET 1 TAB ORAL Daily Omega 3 Fish Oil 1,000 Mg Cap (Omega-3 Fatty Acids/Fish Oil) 1 CAP CAPSULE 1 CAPSULE ORAL Two Times A Day Tylenol (Acetaminophen) 325 MG TAB 650 MILLIGRAM ORAL Q6H PRN : Start taking the following new medications Vicodin 5 Mg/500 Mg (Hydrocodone-Apap 5 Mg/500 Mg) 1 TAB TAB 1 - 2 TAB ORAL As Needed Discharge Instructions DIET: Regular DIET RESTRICTIONS: None SPECIAL INSTRUCTIONS: None WOUND/SKIN CARE: [may shower in the am] ACTIVITY RESTRICTION: no lifting over 20 pounds for two weeks FOLLOW-UP CARE: Follow up with Dr. Wilcox in 10 days
Challenges Patients ability to recall medications, dosage, and frequency Interviewers skill level Time constraints Accessibility during nights/weekends for confirmation of med list Multiple Providers
Challenges Language barriers/cultural beliefs Stress of transitioning through healthcare system Accuracy and completeness of medical history obtained from other resources Communication of incomplete home medication list
Electronic Medication Reconciliation
Newest Challenge Transitioning to paperless electronic record Complexity of electronic health record Compliance with provider to use electronic medication reconciliation Efficient up dating of medication record

More Related Content

Electronic Medication Reconciliation

  • 1. Electronic Medication Reconciliation Phelps County Regional Medical Center Karen Clover, BSN, RN Pam Karr, MSN, RN-BC
  • 2. Patients Presentation Patient presents to the ED Nurse obtains current medication list Available for viewing by ED physician
  • 3. Screen shot of what nurses review on admission
  • 5. Screen shot of ED med list
  • 6. Patient admitted to facility Patient arrives to floor Nurse reviews previous med list and confirms accuracy
  • 8. Patient transferred within facility Screen shot of physicians med rec with transfer
  • 9. Discharge Physician screen shot of d/c med rec
  • 10. Phelps County Regional Medical Center Discharge Medication List / Discharge instructions Patient Name: Patient Joe Report Status: Signed Account Number: Report Number: 0525-0024 Attending Physician: PLEASE KEEP THIS LIST BRING IT WITH YOU IF/WHEN YOU MUST RETURN TO T ***NOTE: Patients and families are reminded to discard old lists and to update any records with all medication p Discharge Instructions ALLERGIES Coded Allergies: IVP Dye (Severe, ANAPHYLAXIS 04/01/11) Penicillin's (05/17/11) PRESCRIPTIONS Continue taking these medications: Norvasc (Amlodipine Besylate) 10 MG TAB 10 MILLIGRAM ORAL Daily Prilosec (Omeprazole) 20 MG CAPDR 20 MILLIGRAM ORAL Daily Synthroid (Levothyroxine Sodium) 75 MCG TAB 75 MICROGRAM ORAL Daily Caltrate-600 With Vit D Tab (Calcium Carb/Vit D3/Minerals) 1 TAB TABLET 1 TAB ORAL Daily Omega 3 Fish Oil 1,000 Mg Cap (Omega-3 Fatty Acids/Fish Oil) 1 CAP CAPSULE 1 CAPSULE ORAL Two Times A Day Tylenol (Acetaminophen) 325 MG TAB 650 MILLIGRAM ORAL Q6H PRN : Start taking the following new medications Vicodin 5 Mg/500 Mg (Hydrocodone-Apap 5 Mg/500 Mg) 1 TAB TAB 1 - 2 TAB ORAL As Needed Discharge Instructions DIET: Regular DIET RESTRICTIONS: None SPECIAL INSTRUCTIONS: None WOUND/SKIN CARE: [may shower in the am] ACTIVITY RESTRICTION: no lifting over 20 pounds for two weeks FOLLOW-UP CARE: Follow up with Dr. Wilcox in 10 days
  • 11. Challenges Patients ability to recall medications, dosage, and frequency Interviewers skill level Time constraints Accessibility during nights/weekends for confirmation of med list Multiple Providers
  • 12. Challenges Language barriers/cultural beliefs Stress of transitioning through healthcare system Accuracy and completeness of medical history obtained from other resources Communication of incomplete home medication list
  • 14. Newest Challenge Transitioning to paperless electronic record Complexity of electronic health record Compliance with provider to use electronic medication reconciliation Efficient up dating of medication record