Lecture 5 - Inpatient pharmacy practice and medical records Flashcards

(60 cards)

1
Q

what is the purpose of the joint commission?

A

to maintain the standards of healthcare. they “check up” on facilities and accredit them

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2
Q

differentiate between a centralized and decentralized hospital

A

centralized —- one pharmacy serves the entire hospital

decentralized —- one central pharmacy and many “satellite” pharmacies

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3
Q

the pharmacy and therapeutics committee is chaired by ____ and usually cochaired by _____

A

chaired by a physician and cochaired by the pharamcy director

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4
Q

what is the duty of the pharmacy and therapeutics committee

A

to make important decisions/changes for the hospital formularies, policies, and procedures

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5
Q

besides the pharmacy and therapeutics committee, name some other committees

A

infection control
quality improvement
falls prevention
antibiotic stewardhsip
anticoagulation

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6
Q

what are some things that a hospital pharmacist can do

A

IV TO PO conversion
renal dosing conversion
therapeutic interchange or formulary interchange
anticoagulation monitoring (warfarin)
antibiotic surveillance
consult
vancomycin and aminoglycoside dosing

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7
Q

what is med rec? (medication reconciliation)

A

comparing the patient’s current list of medications against the physician’s orders

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8
Q

who administers medication to patients in the hospital

A

nurses

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9
Q

what are the 4 steps of the medication order process (include the 5th step if the script was paper)

A

order
transcribe (not in e systems)
verify
dispense
administration

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10
Q

what is the “indication” of a medication

A

why the person is taking it

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11
Q

what does CPOE stand for

A

computerized physician order entry

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12
Q

is there anything wrong with
“apply to the affected area”

A

YES
the nurse needs to know where to put it. prescriber must be contacted

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13
Q

medications in hospitals are dispensed as….

A

unit dosing

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14
Q

What are the 3 ways in which a medication can be delivered to a patient

A

-by hand (by the technician)
-robot
-pneumatic tube system

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15
Q

who ADMINISTERS medication

A

the nurse

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16
Q

what is used by nurses to verify that they are giving the correct medication to the correct patient?

A

bar coding

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17
Q

what is a medication error?

A

any PREVENTABLE event that may lead to innapropriate med use or patient harm

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18
Q

where do most errors occur in the medication cycle?
(choices: ordering, transcribing, dispensing, administration)

A

ordering

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19
Q

category A-I medication errors

which is the an error that may have contributed or resulted in the patient’s death?

A

category I

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20
Q

categery A =
category B-D =
categriy E-H =

A

A = no error

B-D = error, no harm

E-H = error, harm

I = error, death

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21
Q

if a presciber wants to order a 5 mg tablet of acetaminophen, how should he write it?

5.0
5

A

5

NO TRAILING ZEROS

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22
Q

A prescriber wants to write for 0.5 mg. how should he write it

.5
0.5

A

0.5mg

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23
Q

is QD and QOD allowed in writing inpatient medication orders?

A

NO

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24
Q

what is the purpose of the medical record

A

-tool for cimmunication btwn healthcare providers

-billing and reimbursement of claims

-legal proceedings
–eduation
-quality assurace

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25
what are the 2 kinds of medical records
paper charts or folders EMR (electronic medical record)
26
what are some advantages of EMR over paper
legible spell check disaster recovery -mutiple people can use chart at the same time -accessibility -space savings -drug-drug and drug-allergy interaction checker
27
what are some DISADVANTAGES of EMR
-cost of implementing the system -training -power outage/tech issues -risk for data breach -CUT AND PASTE ERRORS
28
what is the organization that allows healthcare providers greater patient access to information geenerated at other facilities?
RHIO ---- regional health information organization
29
what is the largest public health information exchange, serving NYC and long island
healthix
30
_____ has the claim to the medical records, but they ultimately belong to _______
HOSPITAL has the claim, but they ultimately belong to the PATIENT
31
What is on the "face sheet" of a medical record
patient medical record number and patient demographics
32
what is on the "H&P" portion of the medical record
health and physical patient demographics chief complaint present illness medical history surgical history home meds allergies social history family history ROS (review of systems) PHYSICAL EXAMINATION (PE) impression/assessment plan
33
what is on the ROS "review of systems"
what the PATIENT TELLS US ie: im nauseous and have chest pains
34
what does MAR stand for and what is it
medication administration record record of the medications administered to the patient pharmacists use this to determine if a patient received the drug, at what time, and how often the patient is using a prn medicaiton
35
the MAR should include which things
time of administration nurse who administered route of administration reason for administering PRN med reasons for NOT administering (ie: pt refuse, blood pressure too low) pain scores, fingerstick blood glucose
36
"im nauseous"
s
37
"start cephalexin 500mg q 8 hours x 10 days"
p
38
"based on the findings, pt has a UTI"
A
39
order repeat CBC
p
40
right ankle is tender to the touch
o
41
CXR is suggestive of pneumonia
A
42
fasting blood glucose = 110mg/dL
o
43
what is BMP
basic metabolic panel provides info on electrolytes, renal function, metabolic state
44
what is CBC
complete blood count one of the most commonly ordered blood tests
45
what is UA
urinalysis
46
what is usually the FIRST set of labs ordered
BMP (basic metabolic panel)
47
what is one of the most commonly ordered blood tests
CBC
48
How does a pharamcist use a medical record
5 steps of care process collect assess plan implement follow up - monitor + evaluate
49
when should patient data collection occur
pre-encounter mid-encounter post-encounter
50
where in the chart can you find the ECG
cardiology
51
where in the chart can you find insurance information
dashboard/face sheet
52
where in the chart can you find "pt smokes 1.5 packs a dat"
social history
53
where in the chart can you find "chest clear to auscultation"
physical exam or progress note
54
where in the chart can you find the comprehensive metabolic panel
labs
55
where in the chart can you find the psychiatry consult note
consultaitons
56
where in the chart can you find DNR documents
legal
57
where in the chart can you find next of kin
family history
58
where in the chart can you find the list of home medications
H&P (history and physical) but this would be in the history part
59
where in the chart can you find the weight of the patient
many places initial history physical
60