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SDS Accreditation Update
Reconciliation form should show stop, start dates
Indicate who instructed patient to stop medications
Anyone can make a list of medications dictated by a patient, but to fully comply with The Joint Commission's requirement to reconcile medications taken by your patient, your documentation needs to address more than just the name of the medication.
At Lakeshore Surgery Center in Fort Gratiot, MI, the first step in improving the center's ability to reconcile medications was to move away from listing medications within another admission form to designing a separate form to be used just for medication information, says Lynn Burgett, RN, BSN, administrator. "Our medication reconciliation form is the result of four or five trials of different forms," she says. "We produced the first form, then as we piloted its use, we gathered comments from nurses who identified space needed for other information," she says. [See a copy of the medication reconciliation form]
The form has space for the name of the prescription or over-the-counter medication taken by the patient as well as any herbal medications, the dose, the frequency, and instructions about stopping and starting the medication, says Burgett. "In the initial version of the form, the column that the nurse completed for the date the patient stopped taking a medication, such as Coumadin [warfarin], just included the date," she says. "Our surveyor pointed out that there was no identification of who instructed the patient to stop taking the medication and therefore, it appeared that the nurse gave these instructions." Now, the column identifies the physician who told the patient to stop taking the medication, she says.
3-4 day leeway
To identify potential risks related to anesthesia and patient medications, Burgett's staff makes pre-op calls three to four days prior to surgery. "This gives us time to identify medications that might pose a problem and talk with the patient's physicians," she says. Her nurses also have a protocol related to medications that has been developed by the center's anesthesiologists, she says. "This protocol enables nurses to talk to patients about what is safe to take on the day of surgery and what is not," she says. The protocol also prompts the nurse to discuss the use of some medications and herbs with a physician, she adds. Although most patients can be reached several days prior to surgery, occasionally nurses will talk with them the night before, she admits. "The only time we have to postpone surgery is if these patients are taking anticoagulants and have not discontinued their use," she says.
Although the form is simple to use, it does add extra time for the discharge nurse, Burgett points out. "The nurse goes through each medication on the list, explaining what can be restarted on which date," she says. "The discharge nurse also writes the information on any prescriptions given on the day of surgery and explains their use," Burgett says.
Even with the extra time required, the form is very beneficial to staff and patients, says Burgett. "Not only do we make sure we accurately identify medications, but the completed list given to the patient at discharge is a tool they can carry to their physician at the follow-up visit to ensure an accurate list in their physician's chart," she says.