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Policies,Clinical,UWHC Clinical,Department Specific,Pharmacy,Decentral

Pharmacist Clinical Monitoring (3.3)

Pharmacist Clinical Monitoring (3.3) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Decentral

3.3







Effective Date:

June 2002
Pharmacy Policy Manual
Chapter: Decentral
Operations Procedure Manual
Chapter:

Policy: 3.3
Original
Revision 08/14
Page 1
Of 3
Title: Pharmacist Clinical Monitoring

I. POLICY: All patients admitted to UWHC will have their medication therapy
monitored daily by a clinical pharmacist. Pharmacists will document the completion of
this review in the patient’s electronic medical record within Health Link.

II. PURPOSE: To define and document pharmacist clinical monitoring to facilitate
patient profile review, hand-off communication among pharmacists using SBAR
(situation, background, assessment, recommendation) communication, to minimize
adverse drug events, and to ensure the appropriateness of a patient’s drug therapy.

III. PROCEDURE:
A. For all patients admitted to UWHC, pharmacists will perform a daily medication
profile review, and formulate a plan to resolve any drug therapy concerns.
B. The pharmacist will consider the following patient-specific information when
monitoring for appropriateness of drug therapy: the patient’s diagnoses,
comorbidites and concurrently occurring conditions, the medication interview
(Administrative Policy #7.60 Medication Reconciliation), current inpatient
medications, relevant laboratory values/results medication administration record,
and other pertinent information in the patient’s medical record.
C. Documenting the completion of a daily patient profile review in the rounding
navigator will indicate at a minimum a pharmacist review of the following data
has been performed:
1. Age, sex, height, weight, and renal/hepatic function.
2. Pregnancy and lactation status.
3. Appropriateness of the dose, route, rate, timing and frequency of
administration, indication and therapeutic duplication of all medications.
4. Available laboratory values and microbiology results.
5. Appropriateness of antimicrobial therapy regimens which may include
anticipated/planned stopped dates.
6. Potential drug-drug, disease-drug, food-drug interactions.
7. Adherence with UWHC Pharmacy and Therapeutics (P&T) Committee
approved medication use guidelines/protocols.
8. Targeted or therapeutic drug monitoring and pharmacokinetics, and
adjustment of drug regimens if necessary.
9. Drug pharmacodynamics and adjustments of drug regimens if necessary.
10. Review documented adverse drug reactions/allergies and report new
occurrences via Patient Safety Net (PSN).
11. Review for disease progression and/or resolution of symptoms (e.g. pain).
12. Communication of necessary information to pertinent health care providers,
patients, caregivers, and encourage health promotion and prevention.







Effective Date:

June 2002
Pharmacy Policy Manual
Chapter: Decentral
Operations Procedure Manual
Chapter:

Policy: 3.3
Original
Revision 08/14
Page 2
Of 3
Title: Pharmacist Clinical Monitoring

D. Pharmacists will use the SBAR method to standardize all hand-off
communication (Policy 3.20) using the RPh Monitoring Report or the approved
monitoring forms and the pharmacist’s shift report sheet or the Sign Out Report
within Health Link.
E. Pharmacists will use the Rounding Navigator to document:
1. Completion of a daily medication profile review (as described in C. above)
2. Pharmacists will click on the Daily Profile Review Completed tab and click
“yes”.
F. Pharmacists will use the Admission Navigator to document:
1. Completion of admission medication reconciliation
a. Comparisons between the pharmacist admission medication history and
admission orders will be conducted by pharmacists
b. Pharmacists will clarify with the admitting provider all medication
discrepancies noted
c. All discrepancies will be documented using the RPh Med Rec Note.
d. The Medication Reconciliation Completed for Admission button needs
to be marked.
G. Pharmacists will use the Transfer/Post-op Navigator to document:
1. Completion of transfer or post-op orders for medication reconciliation
a. Pharmacists will reconcile the patient's new (transfer) medication
orders versus their current inpatient MAR and their pre-
hospitalization home medication list and contact the prescriber
for any new discrepancies noted.
b. Pharmacists will clarify with the prescriber all medication
discrepancies noted
c. The Medication Reconciliation Completed for Transfer/Post-op
button needs to be marked.
H. Pharmacists will use the Discharge Navigator to document:
1. Completion of discharge medication reconciliation
a. Comparisons between a patient’s discharge medication orders,
current inpatient medication profile, and the pharmacist’s prior to
admission medications list
b. Pharmacist will clarify with prescribers all medication
discrepancies noted
c. The Medication Reconciliation Completed and the Pharmacist
Discharge Medication Reconciliation Status buttons need to be
marked.
2. After completion of a patient medication discharge counseling by the
pharmacist, the Pharmacist Discharge Education Complete button will be







Effective Date:

June 2002
Pharmacy Policy Manual
Chapter: Decentral
Operations Procedure Manual
Chapter:

Policy: 3.3
Original
Revision 08/14
Page 3
Of 3
Title: Pharmacist Clinical Monitoring

marked. The pharmacist will also document all medication teaching
completed under the Patient Education tab in Health Link.
3. Other interventions, notes, etc. will be utilized by pharmacists (as described
in E-H above) using RPh notes in Health Link.

I. Pharmacy residents, interns, and students requiring evidence of monitoring for
evaluation/grading purposes may:
1. Use their own monitoring forms with preceptor approval. He/she may be
expected to transfer all necessary daily patient monitoring information to the
RPh Monitoring Report or the approved clinical monitoring form.

VI. Coordination
A. Originally authored by: Lisa Gryttenholm, RPh, PharmD and Brandon Ordway,
PharmD.
B. Updated by: Lisa Gryttenholm PharmD.
C. Reviewed by: William Tanke, RPh, Michelle Thoma, PharmD, and Phillip
Trapskin, PharmD, Jessica Mahoney, MS, PharmD.
D. Committee approval by: Pharmacy Practice Committee (10/09).




Approved By:_______________________________
Director of Pharmacy

Date:__________