45 Medication Chart Review
Outcome
Ensure current, accurate and clear documentation of medications on the medication chart to facilitate safe and efficacious administration of medicines to patients.
Potential Risks
Inaccurate medication chart documentation can lead to inappropriate administration of therapy, potentially leading to patient harm.
Course
This EPA is undertaken in PHRM3101 or PHRM3102.
Entrustment level
The anticipated entrustment level for PHRM3101 and PHRM3102 is 2-3.
EPA Template
| Element | Performance Criteria Description |
|---|---|
| Medicine Order/Prescription Legality | - Correct patient identifiers are present - Prescribed medicines conform to relevant legislation and legal requirements - Relevant approvals for prescribing of medications or funding have been obtained/displayed (e.g. ID approval, LAM, PBS authority granted, etc) |
| Allergies and Adverse Drug Reactions (ADRs) | - Allergies and ADRs are clearly documented (including details of reaction and when the reaction occurred) - ADR stickers are attached to hard copy medical records, including NIMC |
| Medicine Order/Prescription Clarity | - The medication chart/MAR has: Medicines the patient was taking prior to admission either prescribed correctly or omitted with intention, and clear documentation of that intention Clear documentation of dose and frequency changes from the Patient Medication History (i.e. on NIMC/clinical notes/MAR) - If true duplications are found, doctor appropriately contacted and duplicated medication ceased |
| Appropriate Choice of Medicine | - New medicines are reviewed in line with reason for admission/diagnoses - Continuation of each medication is justified by a clear indication and achievement of goals of therapy - Principles of evidence-based medicine is applied, ensuring appropriate choice of medicine, including likelihood of adverse effects, compared with therapeutic alternatives and ways to minimise adverse effects - Dosage form, route and method of administration are considered |
| Dose Review | - The dose is checked for each medication with respect to: Approved dosing ranges from reliable reference sources Individual patient and disease factors (e.g. age, weight, renal/hepatic function, concurrent illness, etc) Potential drug interactions Dose conversion when route or formulation changes |
| Route and Timing of Dose | - The most appropriate route has been selected and is viable (e.g. oral in preference to IV) - The intended time of dose is recorded on the medication order and is appropriate with respect to food/feeds, administration rounds, scheduled surgery, investigative procedures and therapeutic drug monitoring requirements - The frequency matches the administration times; check that medications have been administered (any missed doses should be followed up and the reason documented in the Medical Records) - Specific days for weekly, monthly and alternate daily dosing are annotated and days where doses are to be intentionally omitted are documented - First dose times in MAR are appropriate |
| Selection of Formulation, Concentration or Rate | - The formulation is appropriate for the patient considering: visual impairment, physical dexterity, swallowing difficulties (speech pathology review) and other patient factors, e.g. risk of overdose or diversion - Administration advice provided where needed, including: Crushing of oral medicines Parenteral medicines – dilution, compatible fluids, rate of administration, method of administration Handling of hazardous medicines, e.g. cytotoxic/teratogenic |
| Review and Interpretation of Patient-Specific Data | - Clinical data e.g. laboratory investigations, clinical observations (temperature, pulse, blood pressure, bowel function, pain scores, mobility) and progress notes have been accessed - Diagnoses and treatment plan reviewed – check therapy prescribed is in line with plan and appropriate - Clinical data has been accurately interpreted with respect to: clinical diagnosis and patient’s current clinical state, past medical history and pathophysiology of disease(s), specifics of medicine (e.g. time to effect) and desired outcome and potential for medicine to be causing adverse effects - Effectiveness of treatment and potential adverse effects are monitored - Missing observation and laboratory data is identified and requested where needed - Review for missing therapy (e.g. laxatives whilst on opioids, VTE prophylaxis) |
| Drug-Drug Interactions | - All common, well-documented drug-drug interactions are identified, including prescribed and non-prescribed therapy (including CAMs, alcohol and nicotine) - Clinical significance, potential consequences of drug-drug interactions and the probability of an adverse outcome occurring are assessed including discussion of appropriate course of action |
| Drug-Patient and Drug-Disease Interactions | - Identification of patient groups at risk of drug-patient and drug-disease interactions (e.g. use of sedatives in an elderly patient at risk of falls, NSAIDs in renal failure) - Identify the potential consequences of drug-patient and drug- disease interactions, including likelihood and clinical significance - An appropriate course of action (if any) is taken to minimise potential harm for the patient |
| Drug-Nutrient Interactions | - Identify the medications that interact with food (including enteral or parenteral feeds), if any - Identify potential consequences of drug-nutrient interactions, including probability and clinical significance and appropriate course of action |
| Drug Availability | - Confirms that medications are available on the ward - Prescribing conforms with hospital guidelines and formulary restrictions, and annotated appropriately - If a medication or combination product is not stocked and patient does not have own supply or alternate source of supply unable to be sourced, prescriber is contacted to review and prescribe alternative medicine |
| Storage | - Appropriate storage of medications is ensured on the ward and documented (e.g. fridge items, S4/S8 Monitored Medicines) |
| Accountability | - Pharmaceutical review is documented according to local guidelines |
