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Medication Administration Program

This revised tool provides information and resources for accessing and understanding MAP policies and responsibilities. It evaluates medication systems and includes sections on HCP orders, OTC methods, vital signs, and medication documentation.

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Medication Administration Program

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  1. Medication Administration Program DDS MAP Technical Assistance Tool Revised 3/15/2018 01/18/2019

  2. Objectives • To become familiar with Technical Assistance Tool sections • To know how to access MAP resources • Required • Informational • Training

  3. Resources • Mass.gov/dph/map • Policy Manual • Oversight and Review • Technical Assistance Tool • Training Tools • Responsibilities in Action (RIA) • Videos and Webinars

  4. MAP Monitoring Tool • Tech Assist Tool • Evaluates a medication system • Sections within the tool • Correspond with MAP Policies

  5. mass.gov/dph/map

  6. MAP Technical Assistance Tool

  7. Section A HCP ORDERS

  8. HCP Orders • Health Care Provider (HCP) Orders • Valid, signed and dated • Includes a dose • Prior authorization, med not available, etc. MAP Policy Section 13

  9. HCP Orders • PRN- frequency, target signs and symptoms, instructions for use • PRN- hours apart from scheduled doses • PRN- ‘pain’, ‘constipation’, ‘anxiety’ is defined; unless the person self-reports MAP Policy Section 13

  10. HCP Orders • PRN Orders • No Ranges For example: • 2 tabs NOT 1-2 tabs • 10 mLs NOT 5-10mLs • Every 4 hrs NOT every 4-6 hrs MAP Policy Section 13

  11. HCP Orders • Posted and Verified • Staff signature, date, time • Below the signature of the HCP MAP Policy Sections 13

  12. HCP Orders • Telephone orders • Signed by the HCP • Posted and Verified twice MAP Policy Sections 13

  13. HCP Orders • Protocols; signed and dated by the HCP, Posted and Verified by staff

  14. HCP Orders • Changes in med orders are handled as new orders • Prescriptions are not used as HCP orders • Outdated HCP orders are not in current use • New orders are obtained after a hospital discharge (transition of care) MAP Policy Section 13

  15. Hospital Discharge Orders

  16. MAP Resource

  17. MAP Resource

  18. HCP Orders • HCP order forms listing multiple medications, after a med is dc’d, staff may print in margin: • DC/date/initials and • ‘see new order’, if applicable

  19. HCP Orders • Exhausting the current supply of medication • There is a new medication order which reflects the change MAP Policy Section 13

  20. HCP Orders • Medication container has been ‘flagged’ • The medication container is not written on by staff

  21. HCP Orders • The old order is dc’d and the new order transcribed on the medication sheet MAP Policy Section 13

  22. HCP Orders • HCP orders, pharmacy labels and medication sheets must agree • There is an internal MAP monitoring system MAP Policy Section 13

  23. Section B OTC Method B

  24. OTC Method B • OTC Method B is used for OTCs and Dietary supplements not labeled by the pharmacy MAP Policy Section 06

  25. OTC Method B • Verification process completed • Container is marked with the person’s name, nurse initials, date Tanisha Johnson HL 9-6-yr MAP Policy Section 06

  26. OTC Method B • HCP order is noted by nurse with initials and date MAP Policy Section 06

  27. OTC Method B • OTC Method B verification process is completed each time • The HCP order is updated • A new OTC med or dietary supplement is purchased MAP Policy Section 06

  28. OTC Method B • OTC Method B training is on site and includes: • Name and contact info of trainer • Dated attendance list of staff trained • How to give the med without a pharmacy label (for each OTC med if more than 1) • A complete set of training materials MAP Policy Section 06

  29. Section C Vital Signs

  30. Vital Signs • Each HCP is consulted to determine if VS are required for med admin • Parameters • VS are monitored by staff as ordered MAP Policy Sections 03 & 08

  31. Vital Signs • Documented on med sheet above or below corresponding med

  32. Vital Signs • HCP is notified if VS were not obtained or parameters not followed • Following notification, instructions received are documented Notified Dr. Jones that Digoxin was held for the second day in a row. Pulse was 54 yesterday and 52 this morning. Dr. Jones said to continue with the med as ordered. He said if the pulse is less than 56 tomorrow morning to call back. He may change the dose at that time. Don Stevens

  33. Vital Signs • VS training is on site and includes: • Name and contact info of trainer • Dated attendance list of staff trained • Equipment specific instructions for use • A complete set of training materials MAP Policy Sections 03 & 08

  34. SECTION D Medication Documentation

  35. Medication Documentation • HCP orders are correctly transcribed onto medication sheets • If an edit/correction is required the transcription is crossed out and rewritten • Hospital discharge orders are transcribed onto new medication sheets MAP Policy Sections 06, 08 & 13

  36. Medication Documentation • ‘Reason’ is on the med sheet • Med sheets are clear and organized • Documentation is in blue or black ink MAP Policy Sections 06, 08 & 13

  37. Medication Documentation • All boxes on the med sheet are initialed as given and/or • Acceptable codes are documented in real time • A progress note is written by staff who gave a med but forgot to initial MAP Policy Sections 06, 08 & 13

  38. Medication Documentation

  39. Medication Documentation • Meds not given as ordered are documented correctly including: • Circled initials on the med sheet • Corresponding progress note explaining what happened • Recommendations obtained • If refused, documentation of HCP notification MAP Policy Sections 06, 08 & 13

  40. Medication Documentation

  41. Medication Documentation • Administration of PRN medication is documented correctly including • Initials and time of administration • Reason med was given • Effectiveness (using subjective and objective observations) MAP Policy Sections 06, 08 & 13

  42. Medication Documentation

  43. Medication Documentation • Errors are properly corrected • Staff have signed the signature list • Accuracy checks; completed prior to the start of the new month MAP Policy Sections 06, 08 & 13

  44. Medication Documentation

  45. Medication Documentation • Data tracking (BM, BGM, weight, VS) needed to cross reference for med administration is completed MAP Policy Sections 06, 08 & 13

  46. Medication Documentation • Recorded on the med sheet, above or below the corresponding med medication MAP Policy Sections 06, 08 & 13

  47. Medication Documentation • Seizure record is present, if applicable • Seizure record is available to cross reference for med administration if applicable MAP Policy Sections 06, 08 & 13

  48. Medication Documentation • Emergency Fact Sheet is present • Current Medication List • Allergies are written on HCP orders, med sheets, EFS, etc. MAP Policy Sections 06, 08 & 13

  49. SECTION E Staff Certification

  50. Staff Certification • Acceptable proof of staff certification, for all staff administering meds, including relief staff, is current and on site

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