The use of medications in the absence of non-medical interventions will not be done unless the physician determines the individuals condition is such that medication is the primary intervention to treat the problem. In all cases an ongoing assessment will be done to insure the least amount of medications are given to enable the person to function at their highest level. As a standard of practice, whenever possible, non-medical interventions will be the first choice of intervention to manage the needs of the individual. Use of psychoactive medications will result in the completion of the Psychoactive Drug RAP. This RAP will serve to assess the EFFECTS of MEDICATION on the individual. Following each evaluation for presence of
side effects, a brief note will be written describing the overall effectiveness
of the drug. Effectiveness means
the drug is enabling the person to maintain existing functional status and/or
enabling them to function at a higher level WITHOUT significant side
effects. If BEHAVIOR TRACKING is indicated the
interdisciplinary team will establish the plan for tracking. Behaviors occurring throughout the day
or in a predictable manner will be tracked in specific time periods in lieu of
counting continuously, to establish a credible baseline. Behaviors occurring without a
predictable pattern will be tracked as they
occur. Progress Notes will be written weekly
times three, and monthly thereafter using the Psychoactive Drug Progress
Note. The content of the entry will
reflect the impact of medication on the overall function and well being of the
person. This note will be joint
effort between nursing and involved team members. Individual notes by discipline will be
written as determined by the interdisciplinary team and/or a professional
discipline sees the need. The physician will evaluate the person at
the time of routine visits regarding the continued benefit risk of
medication. Reduction of medication
will be initiated in accordance with federal guidelines. The physician in concert with the
interdisciplinary team will validate use of medications
The RN responsible for care coordinates
medication monitoring. The
physician, pharmacist, and RN work as a team to insure the use of medication is
appropriate and effective. On a
quarterly basis the interdisciplinary team will review the need for continuing
use of psychoactive medications. When evaluating the drug program keep in
mind the definition of drug effectiveness.
The functional status is being maintained or improved with the use of the
medication without significant side effect. Thus the reason for monitoring impact of
the medication and status of the behavior. Once the behavior/mood problem is under control and hoped for results are achieved, it is time to consider a drug reduction program. The Code of Federal Regulations specifies the time frames and circumstances. The TEAM needs to stay focused on getting the best results with the least intrusive methods. Psychoactive medication can serve a valuable purpose when used appropriately. It is the Team�s job to provide on going assessment to insure the best outcomes for the resident.
Debbie Ohl RN, NHA LTC Consultant & Educator, Ohl & Associates 613 Compton Road, Cincinnati, Ohio 45231 Phone / Fax 513-522-6041 [EMAIL PROTECTED] www.greatcareplans.com
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- policy Park Lane MDS
- Debbie Ohl
