Keep medicine profiles accurate and up to date
It can be tedious, but there is no choice
The prospect of spending five to 10 hours per week or more filling out paperwork was not the reason nurses chose their profession. That’s why it’s understandable that many balk at the tedious task of updating patient medication records and transferring the information to Medicare’s 485 form, which is supposed to be an accurate profile of drugs the patient received over the past 60 days.
Still, reconciling 485 forms to medication profiles and home charts is important in order to remain watchful of serious drug interactions. While the Joint Commission does not require agencies to reconcile medication profiles with the 485, it does, however, require in IM 9.20 that a medication profile be kept with the 485 to ensure that Medicare document is updated.
Nurses at American Home Care services in Peabody, MA, struggle with keeping the medication records reconciled.
"I do the monthly reviews and it always seems to be a problem," says Diane Zickell, RN, quality improvement coordinator at American Home Care. "It seems that 50% to 60% of the charts I review aren’t agreeing."
Drug interaction a major concern
This is a universal problem, experts say. The process of reconciling medication profiles with the 485 form breaks down in four places, all leading to the submission of a 485 that is not a true reflection of a patient’s medication:
• Unsigned physician orders.
Nurses receive a verbal order from a physician to add medication or revise current medication. The nurse often fails to generate the proper paperwork within 30 days for physician signature and inclusion in the patient’s medication profile, which is later used to update the 485.
• Updating the medication profile.
While nurses will keep up with physician orders, they forget to update the medication profile contained in the patient record. Without an updated medication profile, it is difficult to generate an accurate 485.
• Not matching the medication profile to the 485 form.
This is the simple but tedious task of taking the medication profile and matching it with the 485 form.
• Failure to include non-prescription drugs.
Because the 485 is supposed to be a complete profile of a patient’s medication history for the past 60 days, over-the-counter drugs need to be included as well. But nurses often fail to ask patients what drugs they may have taken for a headache or a cold.
"What everyone is concerned about is drug interaction," says Betty Dixon, RN, BSN, a health care consultant with Dixon & Associates in Savannah, GA.
While keeping updated medication profiles is not a requirement that will jeopardize an agency’s Joint Commission accreditation, it is a telling sign of an agency’s capability to manage patient care, says Maryanne Popovich, RN, MPH, director of home care accreditation services at the JCAHO.
"Medication side effects can be a significant medical condition in and of itself, but if you don’t know what the patient is taking, you don’t know the reason they are having nausea and vomiting, for example, is because of all the aspirin they have been taking as opposed to the flu.
"This is certainly not an accreditation risk. It may or may not require follow-up. However, if it results in serious patient outcomes, there could be a problem. If the root cause is that you didn’t know that the patient was on certain medication, then you might have a significant issue."
The Joint Commission standards require a medication profile to be kept. It can be the 485 itself, but because the 485 cannot be revised after a physician signs it, it is more practical to keep a separate record and consistently update that record and transfer the information to the 485 every 60 days.
Should nurses rewrite profiles?
At American Home Care, there are two separate records that note changes and revisions to a patient’s medication the medication profile, which is part of the patient record; and the home chart, which is kept in the patient’s home.
Both these records should be updated with each change in medication, says Zickell, but at least one of them (and sometimes both) are not kept up to date. "Because there is such a tremendous paper trail that these nurses have to keep up with, I think all the information on the 485 is not being looked at as diligently as it should be," Zickell says. "They’re not looking at their medication records and matching it with their 485s."
In order to combat this problem, the agency has pondered requiring nurses to rewrite their medication profiles every 60 days along with a patient’s 485 form a time-consuming task, considering that each nurse can have up to a dozen patients.
Zickell says that would be an extreme measure. For now, the agency has instituted a peer review system whereby nurses review medication record and 485s of other nurses. The results are reviewed by the case manager, while Zickell will review a sampling of records to get a feel for compliance.
At Community Home Health in San Pablo, CA, nurses simply compare the medication profile to the last certified 485 form, says Lilia Rosenheimer, MPA, RN, associate director of nursing at the agency. In addition, the nurse goes over medication lists with the patient to ensure accuracy.
In the past, offending nurses have been approached individually, nurses received friendly written reminders along with their paychecks, and the topic was addressed in staff meetings.
While the problem may hinge on negative attitudes toward paperwork, Dixon says, the breakdown in the system is merely mechanical and can sometimes be solved with some clerical help.
In cases where nurses fail to get physician orders signed, a tickler file administered by clerical personnel can improve the rate of signed orders, she says.
"This can be as simple as a red file folder so that it jumps out at them and doesn’t get lost in other paperwork," Dixon says.
That system works like this: A nurse receives a medication order from a physician over the telephone. The nurse generates a written order for the physician to sign. It’s not uncommon for the memo to get lost in the sea of paperwork or forgotten under demands of patient care. Under this system, the nurse would make a copy of the order, and place the original in the patient file and the copy in the red folder. Clerical staff would be responsible for the folder, and for reminding nurses of which orders need to be signed.
Dixon also suggests assigning nurses the task of obtaining physician signatures. In addition to seeing patients, nurses are also assigned to physicians. Each week a nurse will look in a folder and see which orders need to be signed.
"Rather than bother the physician on a case-by-case basis, they batch it," Dixon says. "Physicians typically enjoy organization, and appreciate a health care organization that acknowledges how busy they are."
Even if the agency is diligent about updating physician orders and transferring that information to the 485, the medication profile is not accurate unless it includes over-the-counter drugs.
"The organization may not ask the patient pertinent questions regarding their medication regime," says Popovich. "Because they don’t ask, they will never know. If you do question your patient and you find out that they are taking Advil, Tylenol, and cold medicine, you could be doing an appropriate service to the patient and to the physician."
Popovich says the easiest way to get a clear picture of non-prescription drug use is during a home visit. Asking the patient what other drugs they have taken, and noting drugs that might be sitting on a kitchen table or in a cabinet also give clues to what non-prescription drugs may have been used recently.
Ultimately, reconciling medication profiles is a matter of making it a priority and setting time aside to get it done, experts say. The challenge is finding time in between seeing patients.
"It’s sheer drudgery," says Dixon. "Everybody hates to do it. But it’s like reconciling your checkbook; it’s something you have to do periodically.
"What they have to do is schedule a time to do it. There are things that prevent nurses from doing this. It’s the nature of home care. You might schedule your paperwork for 3 p.m., but you get a call at 2 p.m. asking if you can take four new patients and see them this afternoon. You have to take them because if you don’t, some other agency will. What you have to keep in mind is that everyone has to do it and that it is not going to go away."