ORDERSDocumentation is monitored in several ways. For example, Registered Staff complete a second check of orders faxed to the pharmacy. As well, the SJHCG RAI Coordinators conduct ongoing data quality checks to ensure optimal data accuracy.
PRESCRIPTIONThe Best Possible Medication History (BPMH) is obtained at admission by interviewing the client/family and reviewing medication bottles, pharmacy records, and previous health records. All current medications including prescriptions, over-the-counter, and herbal products are documented. Dis
VERBALWe provide: coordinator's direct phone/extension, email if applicable, best times to call, what to do if can't reach directly (backup contact, voicemail process), after-hours/emergency contacts, response time expectations. Provided verbally and in writing.
READBACKReadback in medication management involves systematic assessment, planning, implementation, evaluation. Staff trained on standards, procedures documented, outcomes monitored. Quality improvement when gaps identified. Aligns with accreditation requirements.
TRANSCRIPTIONTranscription in medication management involves systematic assessment, planning, implementation, evaluation. Staff trained on standards, procedures documented, outcomes monitored. Quality improvement when gaps identified. Aligns with accreditation requirements.
CLARIFICATIONClient rights include the right to respectful care, informed consent, privacy, confidentiality, access to records, refuse treatment, and raise concerns without reprisal. Rights are explained at admission and posted in client areas. If a rights violation is reported, we immediately ensure c
LEGIBILITYLegibility in medication management involves systematic assessment, planning, implementation, evaluation. Staff trained on standards, procedures documented, outcomes monitored. Quality improvement when gaps identified. Aligns with accreditation requirements.
COMPLETEWhere a participant is not able to complete these forms independently, they will be provided to an identified SDM for completion. This process is documented in organizational policies available on the intranet, and specific examples can be found in department procedure manuals.
RENEWALRenewal in medication management involves systematic assessment, planning, implementation, evaluation. Staff trained on standards, procedures documented, outcomes monitored. Quality improvement when gaps identified. Aligns with accreditation requirements.
DISCONTINUEAccess this information on The Pulse intranet through The Pulse/PolicyMedical (search for pharmacy or medication policies). For specific implementation at SJHCG, including forms, documentation locations, or current workflows, consult with your pharmacy department or unit manager who can sh
