Department of Pharmacy Policies & Procedures

Number: 5:02

Effective Date: May, 1990

Revisions: 9/96; 4/00; 10/08; 9/09

Approval: 5/90

Subject: PATIENT MEDICATION PROFILE

 

A. Policy

Pharmacy Service shall maintain a medication profile on every patient in the hospital. This profile will be constantly revised and updated by computer order entry as therapy changes. In order to facilitate continuity of care and provide for patient safety, all information available in the pharmacy about a patient’s medication regimen will be readily supplied to all healthcare professionals involved in the care of the patient. The patient medication profile will be available on-line for every nursing unit using the computerized practitioner order entry (CPOE) system for order entry and current medications will print on the physician rounds sheet.

B. Procedure

1. When a patient is admitted to the hospital the ADT system automatically enters the patient into CPOE system and the pharmacy system creating an active profile.

2. As medication orders are entered electronically or written on the patient, entries are verified in the computer by the pharmacist.

3. Every hour the CPOE system will electronically transfer to WebChart and a local computer in the pharmacy the following reports: Patient profiles for the entire hospital; IV labels batch file; and the cartfill lists. These reports can then be accessed during an intended or unintended downtime of the CPOE system.

4. The pharmacist rounding on any particular patient care unit or with a certain medical team may print copies of the desired profiles for use by the team or patient care unit.

5. Medication profiles are available at each patient care unit via the
CPOE system. Personnel with access approval to the Pharmacy system may retrieve data at the computer work station.

6. When the patient is discharged from the hospital, a total medication profile of all drug dispensed through pharmacy is electronically generated and stored on the network. This profile includes all documentation as well as total number of doses dispensed and charges made.

7. Patient profiles are retained on the computer for up to 5 years so that medication orders from previous visits may be viewed from the computer screen.