Joint Commission International defines medication (JCI 2010) as ‘any prescription medications; sample medications; herbal remedies; vitamins; nutriceuticals; over-the-counter drugs; vaccines; or diagnostic and contrast agents used on or administered to persons to diagnose, to treat, or to prevent disease or other abnormal conditions; radioactive medications; respiratory therapy treatments; parenteral nutrition; blood derivatives; and intravenous solutions (plain, with electrolytes and/or drugs.’
Preparation for medication administration in a hospital begins with the order for medication, in most circumstances written by a doctor. A record of orders for medication (medications prescribed or ordered), the dosage and times the medication and other treatments was administered is kept in the medical chart of each patient.
Frequency of administration is most often ordered on a repeating schedule (ie, every 8 hours). At times the order may be written as a STAT (give right away) order, a one-time order (give just once) or a prn (medications administered “as needed”) order. Standing orders (also referred to as scheduled orders) are administered routinely as specified until the order is canceled by another order.
Before administration and to ensure safe administration, medication records are strictly on hand at time of administration and medication given according the “five rights” namely:
- Right patient
- Right drug
- Right route
- Right dose
- Right time
Documentation of medication administration is an important responsibility. The medication record tells the story of what substances the patient has received and when. Like other health care records, it is also a legal document.
Hospitals usually have policies and procedures regarding documentation of medication administration. Such policies and proceudres would entail that a listing of all current medications taken prior to admission must be recorded in the patient’s medical record and is available to the pharmacy, nurses, and doctors. An established process contained in such medication related procedures may include that this listing of ‘all current medications taken prior to admission’ is readily available so that it can be used to compare with ‘initial medication orders’.
Now, just in case your hospital is been prepared for JCI accreditation, the medical records you keep must comply with two JCI standards to meet its requirements for proper documentation of medication administration.
The first of the two standards mentioned above which your hospital needs to comply with is JCI Standard MMU.4, which states that ‘Prescribing, ordering, and transcribing are guided by policies and procedures.’
Medical, nursing, pharmacy, and administrative staff in your hospital actively collaborate to develop and monitor such policies and procedures.This standard guides the safe prescribing, ordering, and transcribing of medications.
What concerns you as the Health Information Management/Medical Records practitioner directly is the process of transcribing of medications (by doctors, usually the clerking doctor at admission), which includes ‘a listing of all current medications taken prior to admission’ that must be duly recorded in a patient’s medical record, which will then be measurable for complaince by JCI Standard MMU.4, ME 5.
However, do take note your hospital must comply with JCI Standard MMU.4, ME 6 which requires that this listing is important to be maintained in a medical record since it is used to make a comparison between ‘all current medications taken prior to admission’ against ‘initial medication orders’.
The other direct concerns to you when your hospital is been prepared for JCI accreditation is to be beware that your medical records must contain medication documentation as required by JCI Standard MMU.4.3 which states ‘Medications prescribed and administered are written in the patient’s record’ and that this documentation in your medical records have evidence that can show:
- medications prescribed or ordered are recorded for each patient that is measurable by JCI Standard MMU.4.3, ME 1
- medication administration is recorded for each dose, measurable by JCI Standard MMU.4.3, ME 2
- medication information is kept in the patient’s record or inserted into his or her record at discharge or transfer, measurable by JCI Standard MMU.4.3, ME 3
In summary, in case your hospital is been prepared for JCI accreditation, then look out for JCI Standard MMU.4 and its two requirements ME 5 and ME 6, and also JCI Standard MMU.4.3 and its three requirements namely ME 1, ME 2 and ME 3, so that the medical records you keep complys with these two JCI standards and so to meet its five respective requirements for proper documentation of medication administration.
References:
Carol, T, Carol, L & Priscilla, L 1997, Fundamentals of Nursing: The Art of Science of Nursing, 3rd edn, Philadelphia: Lippincott-Raven Publishers
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA
Janet, W & Jane, HK 2010, Health assessment in nursing, 4th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Patricia, AP & Anne, GP 1997, Fundamentals of Nursing: Concepts, Process, and Practice, 4th edn, St Louis, USA, Mosby-Year Book, Inc.
Work Not Documented Is Work Not Done
