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Put Critical Patient Information At Your Fingertips

Ambulatory Safety Monitor, February 12, 2004

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Have integral patient information-such as the patient's current list of medications, medication allergies, and any herbal and home remedies that they take-readily available when you give patients medication. This means critical patient information must be in the medication administration record (MAR) by the caregiver's side or flashing on a computer screen when he or she opens a unit dose.

The following are some tips to organizing patient information so it is easily accessible:

1. Organize the minimum information-such as age, weight, diagnosis, etc.-in your paper or electronic chart. If everyone knows where to find the information, you've won half the battle, says Deb Ankowicz, RN, BSH, CPHQ, director of risk management for University of Wisconsin Hospital and Clinics in Madison, WI.

The other half is training staff to write down the pertinent details. Ideally staff would write the minimum information on the MAR, "but it often may take some digging to find," she says. Another problem is that staff do not streamline this information, says Richard Kaine, MD, a consultant for Quality Management Resources in Hoschton, GA.

Here's an example: "I was holding a medical record the other day for a patient who was in for ambulatory surgery. There were seven different places in the chart to record allergies. Each should contain the exact same information," Kaine says. "But that's nearly impossible, since patients may remember new things each time a caregiver asks about their allergies."

Designate a single spot in the chart so caregivers can easily see the critical information necessary when prescribing medication.

2. Use lists. Make it easy for staff to keep track of medications. Add a preprinted list to your paper records. Add a "yes" or "no" checkbox next to the medication to clarify whether the patient takes it.

Use shaded boxes that easily catch the eye to prevent caregivers from accidentally overlooking this critical information. Create a policy that if a nurse checks a shaded box, he or she must tell the physician before any treatment occurs.

3. Ask about the last dose of medication. Staff sometimes forget to ask this critical question when a patient arrives for surgery: When did you take your last dose of medication(s)/herbal supplement(s)? Kaine says. While the medical record will contain a complete list of other medication(s) the patient takes, it's important to know when the patient last took any of them because some herbal supplements interfere with medications.

Don't just write down a patient's response. For example, if a patient says, "Yes, I took Kava this morning," write it down in the medical record and then notify the patient's physician.

This week's tip is an excerpt from Briefings on Ambulatory Accreditation, a monthly publication that reports on the activities of the ambulatory care accreditors, the JCAHO, and the AAAHC. It illustrates exactly what you and your staff need to do to pass a survey and gain accreditation so that your organization is known for quality and can affiliate with other delivery systems.

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