North Country Hospital Quality Improvement Initiative

How to Use Medication Form for Patient's Medication

1. Go to hospital Intranet page
2. Click on hospital systems
3. Click on clinical eForms
4. The discharge medication form will appear: Fill in the information for each box. You only need to put the patient's name because you will be placing a label over it when completed.
5. List all the medications the patient has been taking prior to admission in layman's terms i.e. one tab twice a day; two tabs at bedtime rather than BID or HS.
6. Medications may be determined from patient report, EMR, nursing home list, old records, patient lists etc.
7. After each medication, click the taken at home box
8. When completed, compare the list against the physician orders
9. If the medication has been ordered, check the order box. If not ordered and you feel the patient should have the med. or there is a discrepancy I  the dosage, you need to clarify immediately. Example: patient states she takes Lantus 25 units at bedtime, but the physician orders Lantus 35 units; at this point the medication needs to be reconciled. If it is a med. such as Docusate that can wait until the physician makes his next round, then it can be addressed at that time.
10. Go to the bottom of the form and click on copy to copy the form. Once you have exited the computer the form is gone - you cannot go back and edit.
11. The form should be placed in the chart with the physician's order form.
12. When the physician makes his next visit to the patient the physician should review the form and make changes as needed. Example: Patient states they took Docusate at home but physician did not order it. At this time an order should be written for the additional med.
13. When the physician has finished with the orders and all orders are completed, the form should be placed in the front under the tab "Discharge Instructions".
14. When the patient is ready for discharge, the physician can use the form as discharge medications instead of using the old cumbersome method.
15. The form can now be reviewed with the patient who received the original along with the other discharge paperwork.
16. The form can be used to fax to outside pharmacies (Kinney's, Brooks) if the patient desires.
17. A copy should be faxed to the primary care MD's office to update records.