Medication Observation and Documentation Training PDF

Medication Storage © 2021 EMO Health. All Rights Reserved. Medication Check-In Part of medication storage and security is putting medications away as soon as possible to prevent pilferage and protect patient privacy All Marisol program staff are responsible for securi...

Medication Storage © 2021 EMO Health. All Rights Reserved. Medication Check-In Part of medication storage and security is putting medications away as soon as possible to prevent pilferage and protect patient privacy All Marisol program staff are responsible for securing the patients' medications PROCEDURE: When new medications are brought into the program (i.e. new resident intake, pharmacy delivery) the medications should be brought to the medication room Put refrigerated medications away asap Place all other medications in a plastic bin and label with a patient sticker Ensure that the nurse doing the resident intake process is aware of these medications and their location for documenting Resident Medication Storage All medications are stored in a resident-specific plastic bin. Each bin should be labeled with a patient sticker After each medication pass, all bins must be locked inside their corresponding resident’s locker When a medication or a new order arrives to the program check the prescription label with the active MOR sheet  Refrigerated Medications Morning shift Medications with refrigeration storage requirements Monitors and documents refrigerator temperature (detailed on the manufacturer package/container) once daily must be stored in the fridge asap after arrival to the facility Delaying proper storage can damage the medication Do not remove the medication from its original package Packaging protects medications from light exposure Store refrigerated medications in the middle of the shelf (Not the door) No food or drink– risk of food-borne contamination  Medication Refrigerator Temperature Log Morning shift nurse is responsible for checking the fridge thermometer and logging the temperature daily Temperature range must remain between 36-46°F If temperature is out of range, notify the nurse manager immediately If temperature is out of range, contact GBLTC Pharmacy to determine if medications can be safely used Medications Allowed on Person Medications used to treat acute episodes, such as rescue inhalers and Epi Pens® may remain in the patient’s possession Document on MOR sheet by filling in the “kept on person” bubble, and write the product’s expiration date on the “exp date” section Remind the patient of proper use and take note of safety information/warnings on packaging List is posted on the medication wall Medication Basics © 2021 EMO Health. All Rights Reserved. Reading a Prescription Label Reading an OTC Package Label  Strength vs. Dose The medication dose and strength are not the same. Be careful when documenting on a medication sheet or record. Strength: 60mg 60 mg STRENGTH: the amount of active Dose: 2 tablets (120mg) ingredient in one unit of the medication ex., milligrams (mg), milliliters (mL) 60 mg DOSE: the amount of medication taken at any one time (by a specific patient) ex., take two tablets, take 5mL  Interchangeable Medication A product containing a drug in the same amounts of the same active ingredients in the same dosage form as other drug products. Most common example : brand-generic interchange: BRAND NAME GENERIC Motrin/ Advil 200mg tabs Ibuprofen 200mg tabs Tylenol 500mg tabs Acetaminophen 500mg tabs Adderall XR 20mg Capsules Amphetamine/ Dextroamphetamine Salts ER 20mg Capsules Proair/ Ventolin 90mcg Inhaler Albuterol 90mcg Inhaler Formulation XL, ER, SR, and DR products are not interchangeable Example: Wellbutrin XL, Wellbutrin SR, and generic forms Prescription salt forms are not interchangeable Example: metoprolol succinate versus metoprolol tartrate  Are these nicotine formulations Nicotine Patches interchangeable? Nicotine Gum Nicotine Lozenges  Route and Frequency ROUTE of administration is how a medication is ingested, i.e., how the medication enters the body. FREQUENCY is how often a medication is taken. For example, once daily, twice daily, three times daily. Medication Documentation © 2021 EMO Health. All Rights Reserved.  Medication Cycle ALL medications must be: Documented Upon arrival When taken/ingested If changed or discontinued When returned to the resident When disposed Observed When taken by a resident Stored Securely in the refrigerator or cabinet/storage unit Medication Documentation All medications that enter the program must be documented Including resident’s Over the counter (OTC) Medications Document all medication prior to storing them (including refills) Admission Medication List Filled out by the nurse doing the resident intake All medications brought to the program by the resident are documented and counted Prescription medications OTC products On-person medications The proper documentation of all medications brought into the program by residents: ü Establishes a clear chain of custody of medications ü Ensures accountability of all medications ü Prevents misunderstandings and confusion for both the program and the residents  Filling Out Admission Medication List 1. Place patient sticker with the Bee Sting resident’s information on the Robert Kraft 1/1/1948 top left of the form 2. Fill out “Allergies” field. If no allergies, do not leave blank. Write “NKDA” or “No Allergies” 3. If the resident has no medications, check the box stating “No Medications at time of admission”  Filling Out Admission Medication List 4. Selecting one medication at a time, transcribe the medication name, Robert Kraft BEE STINGS strength and directions exactly as 1/1/1948 written on the pharmacy label or OTC product package Alprazolam 1 mg Take 1 tablet at bedtime 42 Metformin 500 mg Take 1 tablet twice daily 16 5. All medications brought to the program must be counted at admission. Use a medication counting tray and spatula and record the number of medications 6. Once the Admission Medication List is filled, the Nurse will decide whether to continue or discontinue these medications while at Mirasol. Circle “C” if continued or “D” if discontinued Held Medications Resident medications that are inactive/ not continued are documented on the Admission Medication List These inactive medications can either be disposed or held for the resident while they’re in the program. Held medications are placed in a tamper Robert Kraft’s resistant bag labeled with the resident’s Held Meds name and stored separately from the active medications. They will be returned to the resident upon discharge. AUDIENCE PARTICIPATION A new patient, John Smith, DOB 10/31/83 arrives the program today with the following medications. How would the admission nurse complete the Admission Medication List? Allergies: Aspirin  Medication Observation Sheets After documenting the resident’s medications in the Admission Medication List, we will document each medication on either a Countable MOR Sheet or a Non-Countable MOR Sheet  Countable Medications If unsure if a medication is a countable medication, refer to this partial list. Scan QR code for a more comprehensive list Countable medications are usually medications with higher potential risk of being misused or diverted Controlled medications are documented on the Countable MAR and counted at each shift change  Countable Medications Countable Medications are substances with a higher risk of misuse and/or diversion. Some examples are: Adderall Vicodin Gabapentin Pharmacy labels may contain a red “C” on the label, RX number may start with C, or may contain an auxiliary label  MOR Sheet- Header Fill in the top box with patient name, date form is filled out, and staff initials Transcribe verbatim (word for word) the medication name (including formulation), strength, complete directions for use from the pharmacy label.  MOR Sheet- Header If it’s a new medication, fill in “New Med” bubble, count the medication, and enter the starting quantity. For On-Person medications, select the bubble and write in the product expiration date from the medication package.  Countable MOR Sheet Document shift counts directly on MAR sheet Count is documented in real time to reduce errors in counts STEPS TO FOLLOW and smoother documentation during med hour 1. Count the medication prior to taking the medication and document the START count 2. After observing the amount taken, document the TAKEN quantity If a resident takes half a pill or partial tablet write 0.5 or 1.5 3. Re-count the medication to confirm the END count. If the count is off notify the Program Director immediately Medications Allowed on Person John Smith 11/13/23 CP 2 Epipen Inj. 0.3mg 4/24 Inject 0.3mg intramuscularly as needed for anaphylaxis House Medications All house medications are documented on the Non-countable MOR Refer to the OTC medication packaging and drug facts label for the recommended dose and directions. Write these in the MOR sheet. Morning Nurse is responsible for checking the house medication expiration dates monthly Expirations written as MM/YY = expires on the last day of the month  Medication Refills Before storing medications that are picked up from the pharmacy: Determine if a medication is a refill Review the patient’s current MORs Refill New Order MAR with Exact Same Medication not currently documented on Medication name a MOR Formulation Same medication and formulation but new Strength dosage or new directions Directions Same medication, different formulation ex. Bupropion XL switched to Bupropion SR  Documenting Refills Confirm medication received is a refill and not a new RX John Kennedy 10/1/23 CP Determine if the medication Metformin E.R. 500 mg received is a countable or non- countable medication Take 1 tablet by mouth Once daily Select the appropriate MOR sheet 10/1/23 8:01 am 1 JK CP Document the date, time and 10/1/23 11:05 am 30 CP enter the quantity of medication received Resident does not need to initial, only staff AUDIENCE PARTICIPATION While working in the med room, you receive a pharmacy delivery which includes two medications for resident Paul Blart (DOB 2/2/1982). P.B.’s CURRENT MEDICATIONS: METROPROLOL SUCCINATE E.R. 50MG – TAKE 1 TAB EVERY MORNING AUDIENCE PARTICIPATION How do you document these medications? Refill or new medication? Which sheet do you use to document these medications? Countable MOR or Non- Countable? P.B.’s CURRENT MEDICATIONS: METROPROLOL SUCCINATE E.R. 50MG – TAKE 1 TAB EVERY MORNING AUDIENCE PARTICIPATION Paul Blart 10/1/23 CP Metoprolol E.R. 50 mg Take 1 tablet by every morning 10/1/23 8:01 am 1 JK CP 10/1/23 11:05 am 30 CP AUDIENCE PARTICIPATION Paul Blart 11/14/23 CP Zolpidem 10mg 30 Take 1 tablet by every morning Medication Return Form Used to document the return of medications to the resident when discharging Medications left behind are kept for 14 days to allow for the resident to pick them up. If not picked up, the medications are then disposed Document all medications being returned to the resident Active medications Inactive held medications brought by the resident on intake Resident OTC’s Refrigerated items  Medication Return Form 1. Write the resident’s full name, name of staff member completing the form, and the date 2. Disposal date will be 14 days after resident discharge. Calculate the disposal date and document it 3. Staff writes their initials and acknowledge they checked all medication storage areas and ensured no resident medications were left behind 4. Write the name and strength of each medication being returned to the resident. For Countable Medications count and write the quantity returned  Medication Return Form 5. Medication is returned only to the patient, or an authorized representative 6. The patient or their representative signs and dates the form 7. Staff member signs and dates the form 8. If the patient refuses to sign, then a second staff member who witnesses the medication return process to the resident, signs the form 9. Medication cannot be returned to a resident representative who refuses to sign the form Thank you