Surveyors are looking for multiple things when tracing patient activities related to managing medications. Some of the more important areas to focus on are:
1) Physician Orders must be clear and concise – no therapeutic duplications, no range orders unless clearly defined as what medication to give for what condition, no dual pain scales to follow, pain medications must be ordered for the condition (i.e, do not order Tylenol for fever and mild pain on the same order).
2) Orders are entered timely, complete and signed for – follow the organizations verbal order process for those ‘emergent’ times when medications is not directly ordered by a physician.
3) Pain management must be based on the patients perception – meaning an assessment must be completed prior to providing medication unless it is immediately following a surgical procedure.
4) Medications must be reconciled prior to discharge – look how this process works for outpatients as well.
5) Aseptic storage and delivery of medications to patients in various areas/conditions – is the area clean and is there enough room to safely administer the medication.
There are many variables in the medication management process. The key takeaways are that Physician orders must be clear, concise and complete – not leaving the choice up to nursing solely and lastly that medication management follows the patients condition in a reasonable and timely manner.
For more information, see the elements of performance in the Medication Management chapter for Joint Commission and the medication standards in the CMS Conditions of Participation found in SOM Appendix A.
For related topics check out our “Moderate Sedation Tracing Essentials” course or Moderate Sedation Bundle at C&A’s Quality Academy to ensure your organization is effectively monitoring moderate sedation.