Question: Why must responsible prescribers enter and review medications within Connect Care at discharge from inpatient encounters?
Context: When newly onboarded prescribers first encounter discharge workflows, it may seem easiest to continue to write out medication prescriptions on paper pads.
Apart from the fact that such manual medication workflows over time impose greater informational and safety burdens on prescribers, what other reasons justify the requirement that all medications be entered (ordered) within Connect Care, irrespective of what is manually written?
Connect Care minimum use norms unequivocally indicate that all medications must be entered into the legal record of care (Connect Care) and that medication reconciliation must be done at all discharges or interfacility transfers.
- Manual: Medication Documentation Norms
- Manual: Minimum Use Ordering Norms
- Manual: Medication Reconciliation
Answer: Proper discharge medication management, including entry of all new or changed medications into the Connect Care record of care, is an unequivocal professional and organizational expectation of discharging prescribers. It is not acceptable to manually write out prescriptions without appropriately recording the patient's intended medications in the Connect Care chart.
This requirement is reflected in hospital accreditation standards, medical staff bylaws and College of Physicians and Surgeons of Alberta standards.
Aside from matters of professionalism, regulation and good clinical practice, a failure to properly record medication orders at discharge can have unintended consequences, including impacts on the following areas:
- Community Pharmacy Report
- A "MedRec for Community Pharmacist" report is generated at every discharge once discharge orders are completed. The report lists all medications that a patient should be taking at discharge, highlighting home medications that may have been changed or discontinued.
- The report should be manually faxed to the patient's registered pharmacy (it cannot be automatically sent at this time). In the absence of a preferred pharmacy, the report can be provided to the patient together with any printed prescriptions they are taking to a community pharmacy.
- Decision Supports
- Checks for drug-allergy, drug-dose, drug-drug, drug-disease and drug-lab interactions are flawed if Connect Care does not have a complete and up-to-date medication list.
- Summative Documentation
- Standard provincial templates for summative documents (e.g., discharge summary) sent to Netcare and community electronic medical records automatically incorporate Connect Care medication information.
- Colleague Information Burdens
- Accurate discharge medication records make information flows faster when patients return for outpatient or emergency reassessments.
- Risk of Medication Harms
- Prescriptions missing from medication profiles in Connect Care (such as those manually written at discharge) can result in these medications being overlooked when patients re-present for care.