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Tips for documenting accurate medication lists upon admission

Nurse Leader Weekly, November 24, 2004

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In 204 medication-history interviews conducted out of 2,046 direct admissions to medical-surgical units, pharmacists made 97 interventions involving 55 patients, according to a study conducted by Northwestern Memorial Hospital in Chicago, IL, and published in the August 15 American Journal of Health-System Pharmacy. The most common discrepancy (42%) that pharmacists found when reconciling medications was an omission of a medication that the patient reported taking before being hospitalized.

The Joint Commission on the Accreditation of Healthcare Organizations' (JCAHO) National Patient Safety Goal #8 requires organizations to develop a process for obtaining and documenting a list of the patient's current medications upon admission. The organization must also involve the patient in the process and staff must make the list available to the next healthcare provider when the patient is transferred or referred for more treatment.

The JCAHO will require full implementation of this process by January 1, 2006. Surveyors will check whether hospitals have a compliance plan in place during 2005, according to a source close to the JCAHO.

"[Medication reconciliation] needs to become part of the checklist of admitting a patient," says Grena Porto, RN, MS, a principal with QRS Healthcare Consulting, LLC, in Hockessin, DE. "It just needs to come to the front of the mind when a patient is admitted."

Once you collect this information, where do you keep it? You could create one form for reconciling medications. The form should include

* the dosage and frequency of each medication
* the date and time of the last dose
* information about the patient's compliance with prescribed dosages and frequency
* information about allergies
* a space for the verifier's initials
* a signature line for the physician

Tip: Place the form in a visible location in the patient's chart. The history and physical or nursing assessment are also good forms to document a patient's medications, Porto says, as reconciling medications using these forms can help reduce the workload on a resource-strapped hospital.

Source: Adapted from Hospital Pharmacy Regulation Resource (September 2004), published by HCPro, Inc.

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