Effective Date of This Revision: January 9, 2009
Contact: Medical Director 310-679-9126 , Administration
Applies to:
* Officers
* Other agents
* Staff
* Visitors
* Student clinicians
* Contractors
* Volunteers
* Subcontractors / Business Associates
PURPOSE:
The purpose of this document is to outline policy and procedures for implementing medication orders in the Detoxification Units of BHS’s Chemical Dependency Recovery Hospitals.
POLICY:
Medications (including over the counter drugs, topical preparations, and vitamins), may only be ordered by individuals who are authorized by their respective act to prescribe such and who have been granted privileges at this facility.
PROCEDURES:
A written order signed by the authorized prescriber shall be included in the patient’s record for all medications administered. The medication orders must be complete and include all of the following:
• Name and strength of the medication
• Route of administration (If no route is indicated, oral route is assumed.)
• Frequency of administration (including “PRN” orders)
• Indication for use on PRN orders
• Date and time of writing
• Signature of physician (or physician’ name, if a verbal/telephone order)
Orders containing less than the above information shall be considered incomplete and must be clarified by a licensed nurse with the prescribing physician, the Medical Director, or the alternate physician on duty before they can be acted upon.
Individual prescriptions ordered for patients during their stay shall not be released to the patient upon discharge unless ordered for take home use by the physician.
Over-the-counter medications provided by the facility shall not be sent home with patients upon discharge unless ordered for take home use by the physician.
Verbal or telephone orders for drugs shall be given only to a physician, licensed nurse, physician assistant, or registered pharmacist by a person lawfully able to prescribe. Telephone orders shall be limited to emergencies and situations where it is impractical for the physician to come in and personally give the order. The order shall be entered promptly in the patient health record, on the Physician Order Form, noting the name of the person giving the verbal order and the signature of the person receiving the order. The prescriber shall countersign the order within 48 hours. When the alternate physician on duty has given verbal orders, the Medical Director shall sign the order if the alternate prescribing physician is not on duty the following day. Within 30 days the prescribing physician must sign the original order.
Any patient requiring medications after discharge shall be referred to his or her own physician for continued treatment after stay. The patient shall be instructed on medications that are to be continued at home. The Medical Director or the alternate physician may write a discharge prescription to cover patient until ongoing care is established. The remaining portion of individual prescriptions obtained for the patient may be sent home with the patient if approved by the physician.
PRN orders for Schedule II, III, or IV drugs of the Federal Controlled Substance Act (Title II, Public Law 91513) shall be administered only by licensed nursing staff after adequate assessment of the patient’s status in accordance with facility policy.
The Medical Director or the alternate physician shall review all medication orders at least every 30 days.
Only an authorized prescriber shall write medication orders.
An up-to-date list of authorized prescribers shall be available in all areas where medication is administered or dispensed.
Telephone orders shall be accepted only from individuals on the list of authorized prescribers.
Medication orders that contain abbreviations and chemical symbols shall be carried out only if the abbreviations and symbols are on a standard list approved by the physician members of the professional staff.
