Overview of Medication Management
When it’s three o’clock in the morning and a nurse wakes up a physician for a medication order for something seemingly innocuous, it is often paramount to know what medications the patient is already on and for what problem, as there are a multitude of possible adverse interactions that may arise from unknowing prescribing. This is why medication lists are a traditional cornerstone of the handoff document.
Smart Sign Out goes a step further with its medication list. We employ structured and relational data to allow users to input a medication (using a medication database integrated with the latest FDA-approved medication list) and assign a relationship to any of the patients’ diagnoses. This allows users to identify specifically which diagnoses the patient is receiving the medication for, providing clinical context for a medication list. Furthermore, Smart Sign Out employs structured data to include dosing, frequency, route, and medication start and stop dates (which provides a daily count on the handoff document).
Using relational data, Smart Sign Out added the ability to tie-in notes, which can be assigned to medications in the same way that they can be associated with diagnoses and tasks. This allows users to write quick notes about medications. Perhaps a user is monitoring a medication level or needs to communicate to the discharge planner or clinical pharmacist about some extra footwork required prior to discharge, like a prior authorization or medication teaching needed. This can be accomplished by linking a note to a medication, diagnosis or task.
Lastly, Smart Sign Out also assists with medication reconciliation. Now, users can signify which medications are home meds or new meds when they are adding medications to the list. This feature will help significantly with discharge planning, allowing a rapid medication reconciliation.