Practitioners are being encouraged to utilize One Chart for investigational medication orders to comply with Medical Staff Policy (MS22), facilitate continuity of care (MM01), and promote safe and accurate preparation and dispensing of investigational products (MS09).
The medical record should contain sufficient information to identify the patient, support the diagnosis and document the treatment course and results. One area that has been lacking is the presence of investigational medication orders which are required to request and dispense medication per Medical Staff Policy.
Complete and accurate medication orders need to be accessible to independent practitioners and appropriate health care professionals and staff participating in medication management. Click the policy number below for a listing of the information required for compliance with each policy.
MS22 Medical Records
- Electronic orders are required for requesting treatment and services.
- Types of orders may include:
- Admission, discharge, and transfer orders including medication reconciliation;
- Orders for tests and services;
- Medication orders;
- Consultation orders;
- Nursing and care orders
MS09 Medication Orders
- Patient name;
- Date and time;
- Patient weight (for drugs that are dosed based by weight such as chemotherapy and ALL doses for pediatric patients). Prescribers are asked to indicate a Dosing Weight (DBW) for patients upon admission (in the admission navigator). Note: nursing staff documents dosing body weight on their documentation flowsheets. This is the weight that is programmed into the smart (Alaris) pump;
- Drug name (generic names are utilized unless the product is a combination product);
- Dosage units;
- Diluent if requesting other than the standard 5% Dextrose & Water or 0.9% NaCl;
- Dosage Form/Route of Administration;
- Frequency or interval (all PRN medications MUST include an interval and an indication);
- Frequency/interval ranges are NOT permitted (e.g. q2-4h)
MM01 Medication Management
- gender (sex);
- current medications;
- indication for procedure, admitting diagnosis and relevant problem list;
- relevant laboratory values;
Electronic medication orders create an accurate medication history and allow all healthcare providers precise and specific direction. The detailed order allows the Investigational Drug Service Pharmacist every detail to safely prepare and dispense medication. It also allows the nurse/coordinator guidance for medication administration.