Patient medication records

Q5 Patient medication records should include all EXCEPT ... 

Information required in patient medication records includes name, age and gender of the patient, diagnosis, current medication therapies, and medication allergies. 

East River HIV Center Clinical Research Assistant/Data Analyst Abstracted and recorded relevant data to the HIV prevention study from patient medical records. 

In some cases, it may be prudent to obtain a certified copy for the subject s clinical trial file. For example, if the records are not owned by the investigator or under his or her control, such as patient medical records held by the hospital, depending on the hospital s archiving procedures it would be advisable to obtain certified copies for the clinical trial file in case the hospital loses, misplaces, or intentionally destroys the documents under an established record retention schedule. This is all part of CQA s oversight role regarding the appropriate transfer and authentication of raw data and source documents. 

His present medical history includes chronic obstructive pulmonary disease (COPD) and urinary incontinence. The pharmacy Patient Medication Record (PMR) includes latanoprost drops for glaucoma which was dispensed six months ago. 

Mrs PG, mother of 10-year-old Tanya, came into the pharmacy a few days ago with a prescription for her daughter. The prescription requested penicillin V oral solution 250 mg/5 mL, 250 mg four times a day and flucloxacillin syrup 125 mg/5 mL, 125 mg four times a day, at least 30 minutes before food. Her mother requests information on her daughter s condition, cellulitis. You notice from your patient medication records that Tanya had recently been treated for athlete s foot. 

Encourages written instruction sheets, medications monitoring, and personalized cormseling by the pharmacist Monitors patient compliance with drug therapy Maintains and utilizes patient medication records to prevent unnecessary and potentially harmful drug interactions and other problems (called medication misadventures)... 

Some individuals go to more than one physician, and it is common for a patient to be treated by one or more specialists in addition to a family physician. Some patients are also seeing other health professionals (e.g., dentists, podiatrists, etc.), who may prescribe medication. It is frequently difficult for one prescriber to become aware of all the medications that have been prescribed by others for a particular patient, and many difficulties arise from such situations. For example, one physician may prescribe an antihistamine having sedative properties for a patient for whom another physician has prescribed an antianxiety agent, with the possible consequence of an excessive depressant effect. Even though the patient is seeing different prescribers, he will often have the prescriptions dispensed at the same pharmacy. Therefore, the pharmacist, by maintaining patient medication records, plays an important role in the detection and prevention of drug-related problems. 

Almost all modern pharmacies use a computer to generate the labels for dispensed prescriptions. In addition to generating labels, the pharmacy computer can be used to collate individual patient medication records (PMRs) and highlight any potential drug interactions, both with medication that is currently being supplied... 

Interactions There is only one drug on the prescription. However, it would also be advisable for the pharmacist or pharmacy technician to check the patient medication record (PMR) for any concurrent medication that could cause an interaction. 

Interactions There is only one drug on the prescription. However, it would also be advisable for the pharmacist or pharmacy technician to check the patient medication record (PMR) for any concurrent medication that could cause an interaction. In this case, the patient s PMR indicated that he has epilepsy stabilised on carbamazepine. There is an interaction between carbamazepine and erythromycin (the plasma concentration of carbamazepine is increased by erythromycin). You also note the patient is penicillin sensitive. 

For out-patient prescriptions, it is the responsibility of the pharmacist to perform a clinical check on the prescription. This will follow the same stages that are followed when performing a clinical check on an NHS prescription (see Section 3.3.4). The main key difference is that the hospital pharmacy staff will not have access to the patient s patient medical record (PMR) as this is usually held on the computer of the patient s usual community pharmacy. Therefore, it will not usually be possible to check for interactions with previously prescribed medication. In summary, the following points need to be considered ... 

The request is from a patient with whom you are familiar. She is a regular patient of your pharmacy and upon examining her patient medication record (PMR) you notice regular supplies of phenobarbital. You will also be aware of the opening times of the local surgery and will be able to confirm that the surgery is closed until Monday morning. Therefore, it is a reasonable request for you to supply the medication in this situation. You will need to interview the patient and ascertain that ... 

The pharmacist completes the CP(US) form by adding the quantity, the name of drug and pharmaceutical form and the appropriate dosage instructions. The medicine or appliance is then dispensed and labelled as normal. It is good practice (although not mandatory) to mark the patient s patient medication record (PMR) to indicate that this supply has been made under the Patient Group Direction. 

Mrs Jones brings her husband s prescription into the pharmacy. The pharmacist enters the details of the patient into the computer and realises there is a patient medication record. The prescription is for a new item that is not already on the PMR. The item ordered is timolol eye drops but there is no indication of the strength required nor are there any directions for use for the patient. 

You need to check that the prescription is legal and the dose is safe and suitable for the patient (i.e. it can be dispensed). You notice that the dose is outside the normal dosage recommendations for diclofenac. From the patient medication record it appears that Mr Jones has not had diclofenac before, but you do go out and ask him. 

On performing the clinical check you see that in Appendix 1 of the British National Formulary there is an interaction between warfarin and cimetidine the cimetidine enhances the anticoagulant effect of the warfarin. Has the patient had this treatment before It is not on her patient medication record, so it is best... 

To ensure prescription form details are accurately recorded on patient medication record (audit questions 1 and 2). 

It is up to the individual pharmacist as to what evidence that he or she would like to see to verify that the patient has previously been prescribed the item(s) being requested. Suitable evidence would include old medication packaging, including the dispensing label (usual if the patient has run out of medication), or a repeat medication slip (used to request a prescription form for a further supply from the patient s GP). Alternatively, you could obtain details of the patient s usual community pharmacy and contact them by telephone to verify any previous supply via the patient medication record system. In addition, it would be usual to request to see some form of identification so you can verify the identity of the patient. 

In 1998, Rachl et al. published the results of the 1995 National Clinical Pharmacy Services study that determined the extent of hospital-hased clinical pharmacy services in 1109 U.S. acute care, general, medical-surgical, and pediatric hospitals with 50 or more licensed beds. Pharmacokinetic consultations (i.e., pharmacist review of the serum drug concentration datti and patient medical record with appropriate verbal or written follow... 

Documentation of clinical service is featured and focuses on the very broad requirements of documenting actual activities performed as well as clinician documentation in the patient medical record. One of the key issues addressed is the defining of an intervention. The definition states that an intervention is any action by a pharmacist that directly results in a change in patient... 

Document relevant findings of a patients health status in the patients medical record... 

Clinical practice in an ambulatory clinic may be provided from an office area within the clinic. The patient, patient medical record, physician, nurse, and other practitioners are in close proximity to the pharmacist s office area. Examples of clinics in which pharmacists have provided clinical services include family practice, OB-GYN, anticoagulation, prescription refill, pain therapy, nutrition, and internal medicine. 

Monitor patient drug therapy for safety and efficacy using a comprehensive patient medication record ... 

---