MEDICATION MANUAL Policy & Procedure TITLE: Section: Source:

Distribution:

Self Medication Program for Inpatient services Medication Administration

NUMBER:

MM 15-001

Date Issued:

July, 2008

Capital Health Nurse Pharmacy Committee; Rehab Services All Holders of CDHA Medication Manual

Date To Be Reviewed:

May, 2011

Issuing Authority:

District Medical Advisory Committee

NOTE: TITLE OF POLICY HAS CHANGED (previously: Rehab SelfMedication Program). This policy now applies to all applicable areas in CDHA who have self-medication programs. POLICY 1. The self-medication program provides a process to assist the team to promote and evaluate the patient’s capabilities regarding self-medication. 1.1.The process includes assessment of the patient’s judgment, memory, understanding and functional ability regarding self administration of their medications. 2. The RN/LPN or where applicable, other healthcare provider, must assess and document the patient’s eligibility. 3. An authorized prescriber’s order is required to initiate the self-medication program. 3.1. Any subsequent medication order written by the authorized prescriber is then included in the self-medication program, unless otherwise specified. 4. The RN is to develop the self-medication plan with the patient. 5. The LPN, in approved practice settings, can assess, educate and evaluate the patient’s progress. 5.1. The LPN works in collaboration with the RN in the planning. 6. The RN/LPN or Physician may remove the patient from the program if any of the following are identified: 6.1. unsafe practices Self Medication Program for Inpatient services

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6.2. changes in patient’s health status 6.3. changes in the patient’s discharge plan 7. The pharmacist may recommend to the RN/LPN that: 7.1. a patient’s eligibility for self-medication program be re-evaluated 7.2. an individual medication be removed from an individual patient’s self medication supply

Special Considerations for Medication Regimes 8. Any medication may be eligible under the protocol with the exception of narcotics and IV medications. 8.1. Medication regimes included must be anticipated to be stable for the duration of the self medication fill order/reorder period. 8.2. The following medications may be included ONLY after careful consideration of: 8.2.1. the patient’s ability to safely self administer 8.2.2. the patient population involved 8.2.3. the frequency of administration •

Oral anticoagulants, medications with fluctuating doses and anti-rejection medications.

•

Non-IV injectable medications

•

Bisphosphonates ( ie. Alendronate)

•

PRN medications

•

Refrigerated medications

•

Medications provided in a multi-dose format

•

Insulin by subcutaneous injection

Program-specific Exceptions 8.3. NS Rehabilitation Centre will exclude fluctuating of drugs such as anticoagulants, gabapentin and baclofen. 8.4. MOTP will include immunosuppressants.

GUIDING PRINCIPLES 1. The purpose of the Self-Medication Program (SMP) is to: 1.1. Increase patient’s knowledge concerning their medications. 1.2. Teach the safest and most effective way to take medications. Self Medication Program for Inpatient services

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1.3. Develop skills required to promote independence in self-medication. 1.4. Prepare patients for discharge and promote ability to adhere to drug therapy 2. Patients have a right to make choices and decisions about their care and treatment. 3. Patients are viewed as having capacity and self determination. 4. Building capacity ‘with’ the patient facilitates autonomy, self-esteem and independence. 5. The focus of care is to provide a supportive environment for: 5.1. collaborative relationships with patients/supports 5.2. successful transition to community living

PROCEDURE PROGRAM STEPS RN/LPN Responsibilities

1. Assess the patient and document the following in the progress note: 1.1. Person’s willingness to participate 1.2. Current mental status: orientation, memory, concentration, and judgment 1.3. Primary language and literacy level 1.4. Past experiences administering own medications 1.5. Current understanding of medication 1.6. Patient’s current pattern of adherence to treatment plan 1.7. Manual dexterity/ vision / coordination to open containers, to determine the need for adaptive containers. 1.8. Available supports when patient living in community/ discharge destination 2. Obtain the authorized prescriber’s order to initiate SMP. 3. Ensure that the appropriate locked storage compartment and resources are available depending on the facility. Note: Nova Scotia Rehabilitation Center (NSRC) requires a lockable compartment with 2 keys for the purpose of storing medications. One key is kept in the medication room and one is given to the patient as per protocol. 4. Assess the appropriateness/ eligibility of each medication included in the self-medication program and documents this assessment in the progress notes. 5. Complete the SMP order sheet and sent to pharmacy for processing. Self Medication Program for Inpatient services

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5.1. If the patient’s desired medication administration times differ from standard administration times for the care area, specify the time(s) to appear on the SMP supply pharmacy label. This will be indicated by each medication on the Self Medication Program Order form. 6. Assess the patient’s functional ability to open containers and read labels, in order to determine the need for adaptive containers/ visual aids. 7. The RN determines the appropriate phase and develops the plan in collaboration with the patient. 8. Record the phase of the program on the bottom of all MAR’s. Example:

Started Self-Medication Program October 1, 2007 - Phase 3

9. Ensure that the program is fully explained to the patient and the patient communicates her/his understanding. 9.1.

Document explanations of the program on the Teaching Record and/or Progress Note including the patient’s understanding of and willingness to participate in the program and any concerns expressed by the patient.

10. Provide appropriate teaching and literature to the patient for each eligible medication and document the patient understanding on a Self-Medication Teaching Record or Progress Notes depending on the practice area. Include teaching on the following topics: 10.1. Name(s) of medication 10.2. Reason for medication 10.3. When to take the medication 10.4. How the drug works 10.5. Side effects and precautions 10.6. Importance of taking only one’s own medication 10.7. Any other pertinent information 11. If required, demonstrate how to sign for medications using the patient’s ‘Personal selfmedication record.’ 11.1. If appropriate, keep this record with the patient; ensure that the record has directions understandable by the patient Example: Adalat 20 mg. Take 1 (20 mg) pill twice a day, rather than Adalat 20 mg p.o. bid. Note: This record is not part of the health record. 12. Educate, monitor and record adherence with the program on the ‘Self-Medication Adherence Record’ or Progress Note depending on the practice area. 13. Record all medications on the MAR. Note: The MAR continues to be the permanent record of all medications ordered for that patient during their admission. Self Medication Program for Inpatient services

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Multi-Organ Transplant Program (MOTP) 14. Post transplant patients initiate the Self Medication Program in Phase 1and advance to Phase 2 when ready. 15. Because the anti-rejection medications require daily adjustments to the dosing, the RN checks the medications for accuracy prior to the patient self administering the dose. For this reason, patients do not participate in Phase 3 of the Self Medication program. (Refer to Phases of Program.)

PHASES OF PROGRAM Progression through phase 1 – 3 indicates increasing levels of patient proficiency for selfmedications and decreasing need for staff supervision of same. Not all patients will be required to process through each phase.. The length of each phase depends on the patient’s ability to participate, the projected outcome and their ability to follow the program. If problems arise that renders self administration of medication unsafe and/or impractical for the patient, the RN/LPN discontinues the program, administers the medications to the patient, reports the change in delivery to the physician, and documents on the Progress Notes to inform the team.

16. Phase 1: Total Supervision 16.1.

The RN/LPN retains control of the medications. Note: At the NSRC, the medications are kept in a lockable compartment by the bedside and the key remains with the RN/LPN.

16.2.

At medication times the patient approaches the RN/LPN to indicate the wish to self administer medications.

16.3.

The RN/LPN supervises the patient’s preparing and self-administering medications.

16.4.

If the patient is using an individual Self Medication Record the patient signs for medications taken at that time.

16.5.

The RN/LPN completes the MAR and documents progress on the Self-Medication Adherence Record or Progress Notes depending on the practice area.

16.6.

Once the RN/LPN, in partnership with the patient, determines there are no areas of concern which would require modification of the program, proceed to phase 2.

16. Phase 2: Partial Supervision 16.1.

Provide the patient with the key to the locked compartment; the patient does not need to be supervised when self-administering medications.

16.2.

The RN/LPN conducts daily counts of the medications to further assess any areas of concern and documents this count on the Self Medication Adherence Record or progress notes

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16.3.

Once the RN/LPN in partnership with the patient determines there are no areas of concern which would require modification of the program, proceed to phase 3.

17. Phase 3: Minimal Supervision 17.1.

The RN/LPN conducts weekly medication counts and documents on the Self-Medication Adherence Record or Progress Note depending on the practice area.

17.2.

If any concerns with adherence arise the RN/LPN and patient determine the need to:

17.2.1.

adapt the program,

17.2.2.

offer additional supervision and/or

17.2.3.

revert to another phase

Modified Self Medication Program: This is a modified program for those patients unable to physically self-administer medications but can verbally direct their medication regime. 18. The patient notifies the RN/LPN at administration times and verbally directs the RN/LPN to give the medications. 19. The RN/LPN keeps the key to the locked drawer until the RN/LPN and the patient determine the readiness for the patient to keep the key and assume responsibility to direct the RN/LPN. 20. The RN/LPN records medication administration on the MAR and documents on the Self Medication Adherence Record or Progress note depending on the facility.

ORDERING OF SELF MEDICATIONS 21. The authorized prescriber writes the order for the Self-Medication Program on the physician’s order sheet. 22. The RN/LPN: 22.1.

orders the eligible medications using the SMP Order form

22.2.

reorders the self-medications using the SMP Order Form

22.3.

checks with the MAR for accuracy

22.4.

completes the (re)order form 48 hours prior to the need for a new medication supply and sends the order to pharmacy (based on pharmacy procedures) Note: Pharmacy requires 24 hours notice to fill SMP medication orders

23. Each service identifies a reorder day if necessary for site specific Pharmacy. 24. Upon initiation of the program, the RN/LPN indicates the number of doses needed until the reorder date. Self Medication Program for Inpatient services

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Note: This also applies to any medication that is changed/adjusted mid-cycle between reorder days. 25. When patients go on pass, the RN/LPN order narcotics and prn’s according to the standard pass medication procedure. 26. Pharmacy staff: 26.1.

Provides the self-medication supply for the ordered amount of time.

26.2.

If a dosette is used, provides a set of labels for the RN/LPN to apply to the dosette.

DOCUMENTATION AND HANDLING OF THE SELF-MEDICATIONS Through all phases of the Self Medication Program the RN/LPN: 26.3.

Records all medications ordered on the MAR.

26.4.

Outlines - in pink highlighter - the transcription box of all medications included in the self-medication program. If the patient is placed on the modified self-medication program, outlines the transcription boxes in blue highlighter.

26.5.

Writes the phase and start date of the program on the bottom of the MAR.

26.6.

Uses the abbreviation ‘S’ to indicate that the patient has self administered the medication.

26.7.

Cross-checks all self-medications with the MAR prior to delivery to the patient.

26.8.

Reviews and teaches about all new or changed medications with patient and documents teaching on the Self- Medication Adherence Record or progress notes prior to selfadministration.

26.9.

Ensures any new medications, changes to existing medications or discontinuation of medications are documented on the Self-Medication Adherence Record or Progress Note and Patient’s personal medication record, if in use.

26.10. Makes all necessary adjustments to the supply and check that the supply of self medications coincides with the patients self medication record and the MAR. Documents this check. 26.11. When using a dosette for the patient’s medication program: 26.11.1. labels the dosette with the set of labels provided by pharmacy to indicate what meds have been included in the dosette 26.11.2. places a label with the patient’s name on the dosette 27. NSRC staff - use the Self medication Adherence Record Forms to document. 27.1.1. Keep the Self-Medication Adherence Record form with the MAR during all phases of the self-medication program 27.1.2. The adherence records are located in the medication section of the health record if the patient is removed from the program and on discharge Self Medication Program for Inpatient services

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28. The RN/LPN documents the following on the Self Medication Adherence Record or Progress Notes: 28.1. Phase 1: the patient’s understanding, memory, and functional ability success in choosing correct medication and if required, whether a personal Self Medication Record was used Phase 2: daily counts of medications and any concerns noted, Note: Daily Counts are not required in MOTP. 28.2. Phase 3: weekly adherence and any concerns

RELATED CAPITAL HEALTH DOCUMENTS NSRC Self Medication Order Sheet (CD0086MR) (not part of the Health Record) Self Medicated Teaching Record - NSRC

(CD0420MR)

Self Medication Adherence Record (CD0086MR) Inpatient Medication Record - Transcription and Documentation MM 10-001

HISTORICAL DATES June 2004 (Rehab – Self Medication policy)

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