Accurate medication lists are difficult to maintain especially when a resident is admitted and discharged several times. It seems that each physician treating a patient has their own idea on what medications work best and which should be discontinued. At the end of the day, nurses are faced with the challenge of determining what is really current and what has been discontinued. Add to that, the resident will tell you they take a half of a yellow pill twice a day but may not remember what that yellow pill is or what it is treating.
Then we wonder why we have medication errors, right? In a blog article by Dr. Fred Pelzman, he discussed a new feature being offered on the primary care, office-based EHR that is a “check and balance” in the form of a “soft stop”. This feature allows the patient to mark medications that have changed since their previous visit and serves as a reminder to the provider that either the medication has changed or the patient doesn’t understand how it is to be used. Are patients in physician offices always right? Probably not, however, used as intended, it raises the question “what is really happening with the medications”?
Ideally, as all EHR systems begin to communicate more, we will be able to get a more accurate and real-time picture of what a patient is actually taking, comparing what we think they are on and what’s actually being ingested into their bodies. Does this have a place in post-acute care? Absolutely! Just think of all the short-term rehab residents we care for or the long-term residents who are possibly able to be more independent in their medication regime. Encourage your EHR provider to communicate with hospital providers in your area, make it a collaborative approach so that we don’t spend hours translating orders only to find that the orders are outdated or inaccurate. Stay well, stay informed and stay tuned!