Medication Setup

Purpose: 

To ensure accuracy of client medication setup and clear documentation related to client medication rights. 

Regulation: 144A.4792
Policy: RC-M10

Measurement:

  1. 100% of clients receiving medication management services, have documented clinical note in ClearCare and a completed Medication Setup MAR completed.

Process:

  1. A RN must conduct a face-to-face client assessment to determine what medication management services will be provided and how those services will be provided. This is typically a part of the Comprehensive Assessment. 
  2. The home care provider must prepare and include in the Service Plan a written statement of the medication management services that will be provided to the client. This will be documented on the "Individualized Medication Management Plan" (IMMP) on the client Service Plan.
    1. This must include:
      1. A statement describing the medication management services that will be provided;
      2.  A description of storage of medications based on the client's needs and preferences, risk of diversion, and consistent with the manufacturer's directions
        1. If the client is in need of a locked medication box, the nurse can provide supplies by following the  Providing and Billing Client Supplies process.
      3. Documentation of specific client instructions relating to the administration of medications
      4. Identification of persons responsible for monitoring medication supplies and ensuring that medication refills are ordered on a timely basis
      5. Identification of medication management tasks that may be delegated to unlicensed personnel;
      6. Procedures for staff notifying a registered nurse or appropriate licensed health professional when a problem arises with medication management services; and
      7. Any client-specific requirements relating to documenting medication administration, verifications that all medications are administered as prescribed, and monitoring of medication use to prevent possible complications or adverse reactions.
        1. The medication management record must be current and updated when there are any changes.
  3. Physician ordered medications will have current prescriber orders on file. These will be scanned into the client chart. 
    1. If there are not physician orders on file, nurse will reach out to physician with medication list, asking for physician signature
    2. Once signature is received, signed orders will be scanned into client's electronic medical record.
  4. Medication reconciliation must be completed when a licensed nurse, licensed health professional, or authorized prescriber is providing medication management
    1. The nurse will visit https://www.webmd.com/interaction-checker/default.htm and enter all medications to identify any interactions
      1. If there is an interaction noted, nurse must notify physician for direction if medication should be given congruently. 
      2. When complete, the web page must be saved as PDF and entered into client chart with date in the File Title Name
  5. Once the orders have been received / confirmed, an RN/LPN will setup medications to be administered, in appropriate pill boxes. 
    1. At the time of the setup, the RN must document the medication setup of each individual medication using the Medication Setup Record Form, which will include:
      • The name of the person completing the setup 
      • The date of the medication setup 
      • The name of the medication 
      • The quantity of dose 
      • The times to be administered 
      • The route of administration 
    2. Once the Setup Form is completed, the setup record must be signed and scanned into client chart.
  6. The nurse will confirm the Medication List in client record is accurate to that of the physician orders. If not, the list must be updated immediately. 
  7. An RN must specify, in writing, specific instructions for each client and document those instructions in the client’s record including:
    1. When the medication should be administered (days and times)
    2. Any pertinent details (i.e. must take with breakfast, etc.)
  8. Once nurse has completed the setup of the client medications, he or she will document the clinical note in ClearCare, in the note section of the scheduled visit on employee's shift calendar in CC, with the Tag, "Medication Setup". 
  9. The following information must be included in the clinical note. 
    • Document verification of medication name, quantity of dose, time to be administered, route of administration
    • Document any missed medications and plan to correct
    • Document refills called to the pharmacy and plan to pick up/deliver
    • Document PRN usage and effectiveness
    • Document any signs of drug diversion and plan to correct 
    • Document any signs of side effects and plan to address
    • Example: Medications set up through _______ verifying the name of the medications, quantity of dose, times to be administered and route of administration.   _____ missed medications from previous ____week med set up.  ___ refills called to ____pharmacy – _______________.  ___________ will pick up refills and deliver to client home.  No PRN medications used in the past ____ weeks (or document effectiveness of PRNs). No drug side  effects noted and no signs of drug diversion noted