A thorough medication reconciliation will be conducted by the RN upon admission and at every plan of care renewal, using an updated medication list and by verifying the medications on the bottles. The RN is responsible for obtaining and verifying a complete and accurate list of the medications a patient is taking, identifying any unaccounted changes, checking for any medication interactions, and educating patients.

Nurses (RN/LPN) completing patient care shifts are required to update any orders, monitor medications being given, and determine whether medications need to be reordered. No medication discrepancies should be found during reconciliation.

 

• An RN will complete medication reconciliation at the start of admission.
• Medication reconciliation will occur at every plan of care review, which will be scheduled for review every 8 weeks (2 months) for acute care services, every 10 weeks for RN delegation, and every 26 weeks (6 months) for maintenance services in the EHR system, or if a change of condition warrants a change in skilled need. Medication reconciliation will be signed by a Registered Nurse at each interval.

Best Practice:

1. Nurses working shifts should keep medication orders current, ensuring that the medication profile and eMAR always match the medications they are administering. 
2. Each medication order must contain the following: 

• Medication Name, 
• Dosage form
• Strength of concentration
• frequency/ time
• Route, Indication
• Quantity of medication or duration of time the provider is prescribing for

3. Medications should be listed in the Medication Administration Record and should be identical to the prescription on the bottle, for example, 500 (2 tabs).
4. Medications requiring provider orders include
   • Routine orders: Medication order that is scheduled to be given at the same time each day, or other defined interval.
   • As needed order (PRN): medications that are given based on the occurrence of a specific symptom. These medications may be written giving a dosage range dependent on the severity of the symptom.
   • Orders of limited duration: These orders will only remain on the Medication Administration Record for a limited period before falling off.
   • Taper orders: The medications will decrease in dosages frequency over time. These orders must contain the dosages and intervals for each step of the taper.
   • Titration orders: The medications will increase in dosages frequency over time. These orders must contain the dosages and intervals for each step of the taper, the desired effect, and the parameters of the medication dosage.
   • Hold orders: the orders will occur when a medication is stopped for a temporary period of time before being resumed again. 

It is crucial to appropriately chart all medications as a nurse, as medication errors can potentially occur. To mitigate these errors, it is essential to be attentive during medication passes and orders and ensure the correct patient, time, dose, frequency, and route for every medication. Proper documentation is also vital to complete the task.

At Journey Nursing Services, medication safety is of utmost importance. All staff involved in medication administration must adhere strictly to standards. CNAs need to call their nurse delegator to verify giving medicines outside the scheduled window. Additionally, medications should be given in a distraction-free area with proper lighting and verified against the medication administration record before administration.

1. Employees will only administer medications prescribed in accurate and complete orders.
2. Medication orders must contain:
• Medication name: generic or brand
• Dosage form
• Strength of concentration
• Frequency/time
• Route
• Indication
• Quantity of medication or duration prescribed

3. Medications requiring orders include routine, as-needed (PRN), limited duration, taper, titration, hold orders, and herbal medications or supplements.
4. Nurses are responsible for verifying medication interactions, patient identity, and allergies every shift.
5. An order is required to initiate, change, or discontinue a medication. All medications, including missed or refused doses, require proper documentation.
6. Medications will be given within 1 hour of administration. Nurses may use judgment to provide medication outside that timeframe with proper documentation.
7. Address patient's medication concerns and educate them on the medications given.
8. As-needed (PRN) medications require follow-up within 1 hour of administration, stating effectiveness in terms of the symptom complaint.
9. Notations such as effective, ineffective, or partially effective do not meet documentation standards.
10. First response: Reaction to a patient's first dose of any new medication will be documented in their chart.