Prescribe new med profile to please JCAHO
Prescribe new med profile to please JCAHO
Revamp documentation process with these tips
Nurses with an Alabama agency routinely forgot to write down the names of some medications used by patients, especially if the medication was an over-the-counter drug, such as Bufferin.
"They need to put either the generic name or the trade name, and oxygen has to be listed on the medication profile, also," says Carol Grooms, RN, BSN, clinical manager of Integrated Home Care in Birmingham, AL. The company, which previously was called First American Home Care, has 25 agencies divided among five regions of Alabama.
Slack medication documentation caused problems for four of the company’s five regions when the company was surveyed earlier this year by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. A total of 21 Integrated agencies in Alabama had to improve their medication documentation.
"The surveyor cited us on the fact that we were not classifying medications appropriately on the medication profile," Grooms say. "We did not even have a column for classifications on the medication profile."
Integrated Home Care, which has its headquarters in Baltimore, decided to revamp its medication profile as a first step toward solving the problem. (See Integrated Home Care’s new medication profile, inserted in this issue.)
"Integrated’s National Quality Council recommended that this is something all Integrated offices across the United States should look at," Grooms says.
Each region in Alabama also underwent an extensive quality improvement process to implement the new medication profile and to educate staff on its use.
Grooms says it’s too early for the company to know if the Joint Commission will approve the changes, but internal audits have shown a marked improvement in medication documentation.
Here’s how the company attacked the problem:
1. The company began to use the new profiles.
The company chose three Alabama clinical managers, including Grooms, to lead all process improvement in the state, including use of the new medication profiles. One clinical manager was made responsible for integrity audits, and Grooms was assigned to do follow-up on all of the Joint Commission projects statewide.
Grooms says her job was to work with the other clinical managers and with each agency administrator to review the agency’s efforts to improve its medication compliance.
Within a few months of the last Joint Commission survey, the agency had the new medication profiles in place. Agencies made sure that nurses used the new profile for all ew patients and current patients who were recertified.
That meant that within a few months, the new form was used for all patients.
2. Managers showed staff how to use the new form.
Grooms filled out an example of a medication profile, writing a fictitious patient’s name and drug information. Under the prescriptions heading, the sample profile read in part:
• Start date: 6/30/97
• D/C date: [blank]
• Drug: Librium
• Dose: 5 mg
• Route: P.O.
• Freq: Tid
• Classification from back: AA
• N/C: [blank]
• Food/Drug Contraindications: taught 7/8/97
Each profile includes two duplicate copies and a drug classification list on the back of the form. The classification shows the effects of various types of drugs and lists some side effects and contraindications. (See drug classifications, inserted in this issue.)
Grooms says she told nurses to write the word "taught" and the date under the heading Food/Drug Contraindications to simplify documentation. "That would tell any of the nurses in any office that we could look at the nursing note for that day and see exactly what they taught, rather than having us read every single nursing note to see if they taught something," she explains.
If there are no food or drug contraindications to teach, then the nurse simply writes "zero" in the space.
The next step was to have administrators conduct one-hour inservices on medications for each office. Grooms was on call if agency staff had any questions.
The inservices went through the medication profile point by point, giving these instructions:
• Complete all information that applies to the client.
• Complete start date, name of drug, dose, route, frequency, and classification from the back.
• If you cannot find the classification on the back, use a drug book, and write the classification in under "classification."
• To prevent duplication regarding food/drug contraindications, you may write "taught" and the date. If you taught on July 25, then document on that nursing note what you taught regarding food/drug contraindications.
• If the client has more than four over-the-counter medications, use page two of the medication profile.
3. Supervisors audited forms, targeting problem areas.
Starting in July, several months after the Joint Commission surveys, the clinical supervisors in each office had to review all medication profiles and charts.
If a supervisor saw a problem, he or she would have to call in the case manager and go over the problem. For example, Grooms says, the clinical supervisor might notice on the initial assessment form that the case manager wrote that the patient was taking an over-the-counter drug each night. But the case manager failed to put this on the medication profile.
The audits could be intense, taking up to a couple of hours per day. This process lasted two months, and then the supervisors began to audit the forms only on a spot-check basis.
In the future, they plan to include a look at medication profiles each quarter when they do a utilization review of the records.
If a supervisor finds that a particular nurse repeats mistakes on the forms, then the supervisor will counsel the nurse on paper and place the notice in the nurse’s personal record.
4. The company conducted a full agency assessment.
The last step, which is still ongoing this fall, is to have Grooms and other regional directors conduct full agency assessments of open and closed records to make sure each agency is following the standards.
Grooms says this assessment is as thorough as if she were a Joint Commission surveyor. It includes the following:
• Are they filling out the initial assessment correctly?
• Are they filling out the medication profile completely?
• Are they doing discharge planning?
• Are they giving out discharge instructions?
• Was a form used when a patient was transferred?
• Was the chart closed out appropriately?
The assessment also includes some field visits with nurses, social workers, and therapists. And it involves an environmental review and a look at personnel records.
"That is a lot of work, but that way I can make sure they understand the new conditions of participation and that they’re following all of the new policies and procedures," Grooms says.
This is in addition to what the Joint Commission has required. Each region that failed to meet full compliance on medication profiles has to write an in-depth progress report that addresses medication profiles, medication administration, and the effectiveness of medication for patients, Grooms says.
Then they have to select 75 charts for the Joint Commission to review the plan of treatment, the Medicare 485 form, the medication profile, and nursing notes. The Joint Commission then will make sure all problems are resolved and all medication monitoring standards are met.
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