Policy Manual sample

MDT Home Health Care Agency, Inc. MEDICATION PROFILE/MEDICATION MONITORING MEDICATION ASSESSMENT/REVIEW Policy: Patients receiving medications administered by the agency will have a current accurate medication profile to document the current medication regimen. Procedure 1. Upon admission to the agency, the admitting clinician will initiate a medication profile to document the current medication regimen. 2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessment are performed (recert), and when care is resumed after a patient has been hospitalized. Aged Drug Classification Criteria used in the Medication Profile/485: (N)ew medications: any new drug ordered within the previous 60 days of admission or recert, and the patient was not used for at least 3 months. (C)hange medications: any order change in the medication currently used by the patient, included dosage change, route, frequency, etc. (O)ld medication: any drug continuously used for more than 60 days, and no change was ordered. 3. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patients and family/caregiver as well as other clinicians understand the medication regimen, This includes, but will not be limited to: A. Using the medication profile to evaluate the use of drugs in the home setting. B. Using the medication profile to teach purpose of medication, dosage, routes, Administration times, side effects and contraindications. C. Using the medication profile as a communication tool for other -clinicians involved in the Care. D. Update medication profile with new medications. 4. Each patient will receive appropriate written material for specific medications he/she is receiving, The material will contain information on actions of the medication, potential side effects, contradictions the patient should be aware of, and any special instructions when taking the specific medication. 5. Based on review of the medication profile as well as the written material, changes in the plan of care may be required (complete a Modify order). 6. Any conclusions and findings of patient medication use or monitoring should be communicated to the physician, pharmacist when appropriate and other clinicians. 7. Deviations from taking medications as ordered, will be documented in clinical notes and the physician will be notified. 8. Assessment of the patient for signs and symptoms of dyskinesia, will be completed when the patient is prescribed antipsychotic or neuroleptic medications. 9. Resumption of care orders, re-assessments medications, resume medication orders, continue home medication orders, and obtaining home medication, our Agency prohibits summary (blanket) orders to resume previous medications. Communication is critical when writing orders to reinstate a patient's medication. Blanket orders are dangerous because clinicians could forget to include previous medications that could be vital, or other health care team may misinterpret the order. Orders to simply resume or continue medications have led to errors and are prohibits in our Agency. Medication assessment/review occurs at least every certification period, or more frequently depending on the patient’s needs. Findings of the assessment are reported to the attending physician. Home Health Agency Nursing Manual J-40