Inpatient Prescribing Med Records

Question 1

Types of Inpatient Healthcare Facilities:

Answer 1

Hospitals (General and Specialty)
Rehabilitation Centers
Psychiatric Hospitals
Long-term Care Facilities (Nursing Homes)

Question 2

other facilities

Answer 2

Residential Treatment Facilities
Hospices

Question 3

The Joint Commission (TJC):

Answer 3

Mission: Improve safety and quality of care through accreditation and related services.
Sets and maintains healthcare standards.
Conducts facility assessments.
Publishes annual patient safety goals.

Question 4

Centralized hospital

Answer 4

Centralized: One pharmacy serves the entire hospital.

Question 5

Decentralized:

Answer 5

Decentralized: Central pharmacy with satellite pharmacies near patient units.Central pharmacy with satellite pharmacies near patient units.

Question 6

Outpatient Pharmacy

Answer 6

for discharged patients and employees.

Question 7

Role of Pharmacists on the Medical Team:

Answer 7

Medication reconciliation
ED interviews
Transitions in care (e.g., hospital to rehab)
Discharge counseling
Ensuring appropriate medication usage

Question 8

Medication Reconciliation

Answer 8

Process of identifying a patient’s medication list.
Compares patient’s list to physician’s orders.
Critical for preventing medication errors during transitions of care.

Question 9

Medication Errors:

Answer 9

Any preventable event causing inappropriate medication use or patient harm.
Can occur at various stages of the medication cycle.
Commonly result from poor communication.

Question 10

Medical Records:

Answer 10

Legal documents for patient care.
Aid in communication among healthcare providers.
Serve as proof of events or procedures.
Document complete patient care information.

Question 11

Pharmacist interventions

Answer 11

Ensure the following
Appropriate medication prescribed
Formulary medications
Appropriate dose of medication
Appropriate route of medication
Appropriate monitoring of medication

Question 12

Types of Medical Records:

Answer 12

Paper charts or folders.
Electronic Medical Records (EMR).

Question 13

Components of a Medical Record:

Answer 13

Face sheet
History and physical (H&P)
Consultations
Progress reports
Nursing notes
Lab data
Medication reconciliation
Patient’s orders
Medication administration records (MARs)
Radiology/imaging
Surgical procedures
Review of systems
Physical examination

Question 14

How Pharmacists Use Medical Records:

Answer 14

ollecting data for patient assessment.
Assessing information.
Planning and implementing care.
Documenting interventions.
Monitoring and evaluating patient progress.

Question 15

Pharmacy-Related Components in Medical Records:

Answer 15

Allergies, medication history, physical findings.
Laboratory and diagnostic results.
Clinical and treatment notes.
Problem lists.
Medication administration records.
Orders.

Question 16

How to Collect Data:

Answer 16

Be systematic and organized.
Keep the process simple and relevant.
Avoid over-collecting data.
Be efficient and consistent.

Question 17

Timing of Patient Data Collection:

Answer 17

Pre encounter assessemnt
Mid encounter assessment
Post encounter assessment

Question 18

Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Answer 18

Mission: Improve safety and quality of care.
Maintains healthcare standards.
Conducts facility assessments.
Publishes annual “patient safety goals.”

Question 19

Reasons for TJC Accreditation

Answer 19

Enhances community confidence.
Acts as a marketing tool.
Represents performance improvement.
Required by most residencies.
Attracts qualified staff.
Encourages development.
Acknowledged by some payers.
May reduce liability costs.

Question 20

TJC Patient Safety Goal #3 - Medication Safety

Answer 20

ocuses on safe medication practices.
Label unlabeled medicines before procedures.
Applies to syringes, cups, and basins.
Label in preparation areas.
Caution with blood-thinners.
Record and share accurate medication info.
Compare all medicines taken.
Provide written info to patients.
Stress bringing an up-to-date list to visits.

Question 21

Advantages of EMR

Answer 21

Legible notes.
Accessible charts.
Transcription cost savings.
Space savings.
Multiple users simultaneously.
Automatic lab results.
Spell check.
Disaster recovery.
Drug interaction and allergy check.
Enhanced patient safety.
Electronic prescriptions.

Question 22

Disadvantages of EMR

Answer 22

Cost of implementation.
Transitions in care between systems.
Training required.
Technical issues and power outages.
Security and data breach risks.
Copy-paste errors.

Question 23

RHIO

Answer 23

Regional Health Information Organization.

Question 24

Health Information Exchange

Answer 24

Shares healthcare information among organizations.
Improves patient access to data from various facilities.

Question 25

Healthix

Answer 25

Largest public HIE in NYC and Long Island.

Question 26

Retention of Medical Records in NY

Answer 26

Must keep records for at least 6 years from discharge. Obstetrical and children's records for 6 years or until child is age 21, whichever is longer. 6 years after death. Based on a legal principle of confidentiality.

Question 27

HIPAA

Answer 27

Security standards protect data environments. Privacy standards govern use and disclosure of protected health information (PHI).

Question 28

Components of a Medical Record

Answer 28

Face sheet. History and physical (H&P). Consultations. Progress reports. Nursing notes. Lab data. Medication reconciliation. Patient’s orders. Medication administration records (MARs). Radiology/imaging. Surgical procedures. Review of Systems. Patient statements. Physical examination findings.

Question 29

Consultations

Answer 29

Consultations in various medical specialties, e.g., cardiology, pulmonary, gastroenterology. Consulting services include pharmacist consults for medication-related issues.

Question 30

Patient’s Orders

Answer 30

Orders can be initiated by credentialed personnel like nurse practitioners, physician assistants, and physicians. Orders include laboratory tests, X-rays, procedures, medications, treatments, diet, and activity levels. Always include any patient allergies.

Question 31

Progress Notes

Answer 31

Attending physicians, consulting physicians, and consulting services contribute. Pharmacokinetic assessments, medication counseling, and adverse drug reactions. Case management and social work notes. Respiratory therapy and dietary/nutrition notes.

Question 32

Nursing Notes

Answer 32

Admission assessment, including skin assessment, height, weight, and allergies. Daily flow sheets documenting physical assessments, vital signs, IV access, intake, output, and weight trends. Laboratory results with normal reference ranges and interpretations for uncommon results.

Question 33

Medication Administration Record (MAR)

Answer 33

Purpose: Record of medications administered to patients. Used by pharmacists to verify drug administration, timing, and PRN medication use. Documents time, administering nurse, route, and reasons for PRN medication administration.

Question 34

How Pharmacists Use Medical Records

Answer 34

Collect data (subjective and objective) for patient assessment and care plans. Assess the data to derive meaningful conclusions. Plan and implement pharmaceutical interventions. Document patient-related notes and interventions. Follow up by monitoring vital signs, labs, and progress toward therapy goals.

Question 35

Pharmacy-Related Components in Medical Records

Answer 35

History and physical: Allergies, medication history, pertinent physical findings. Laboratory and diagnostic test results: Disease states, medications, drug concentrations, cultures. Clinical and treatment notes: Progress notes, nurses' notes, consultations. Flowsheets: Daily vital signs. Medication Administration Record. Orders.

Question 36

Data Collection Forms

Answer 36

Forms are customized for specific roles or clinical settings. Data format varies based on practice setting and provider services. Factors influencing data collected: clinical setting, patient care team role, task-driven assessments.