It is a fundamental responsibility of a pharmacist to ensure the safety and efficacy of medication orders.
• It serves as starting point for other clinical
pharmacy activities (medication counseling, TDM, DI, and ADR).
• Organizing information according to medical problems
(for example disease) helps break down a complex situation into its parts.
Goals of medication chart review:
• To optimize the patient's drug therapy.
• To prevent or minimize drug-related problems/medication errors.
Procedure of medication chart review:
The patient’s medical record should be reviewed in
conjugation with the medication administration record. Recent consultations,
treatment plans, and daily progress should be taken into account when determining
the appropriateness of current medication orders and planning each patient’s
care. All current and recent medicate on orders should be reviewed.
Components of medication order review:
• Checking that medication order is written by legal
and local requirements.
• Ensuring that the medication order is comprehensible
and unambiguous, that appropriate terminology is used and that drug names are
not abbreviated. Annotate the chart to provide clarification as required.
• Detecting orders for medication to which the patient
may be hypersensitive/intolerant.
• Ensuring that medication order is appropriate concerning:
- The patient’s previous medication order.
- Patient’s specific considerations e.g. disease state, pregnancy.
- Drug dose and dosage schedule, especially concerning age, renal function, and liver function.
- The route, dosage form, and method of administration.
• Checking complete drug profile for medication
duplication, interactions, or incompatibilities.
• Ensuring that administration times are appropriate
e.g. concerning food, other drugs, and procedures.
• Checking the medication administration record to ensure that all orders have been administered.
• Ensuring that the drug administration order indicates
the time at which drug administration is to commence.
• Special considerations should be given especially in
short-course therapy as in antibiotics and analgesics.
• Ensuring that the order is canceled in all sections
of the medication administration record when the drug therapy is intended to
cease.
• If appropriate follow up on any non-formulary drug
orders, recommending a formulary
equivalent if required.
• Ensuring appropriate therapy monitoring is implemented.
• Ensuring that all necessary medication is ordered.
E.g. premedication, and prophylaxis.
• Review medication for cost-effectiveness.
• Identification of drug-related problems.
- Untreated indication.
- Inappropriate drug selection.
- Sub-therapeutic dose.
- Adverse drug reaction.
- Failure to receive the drug.
- Drug interactions.
- Drug use without indication.
- Overdosage.
Medication chart endorsement:
• Another important goal of treatment chart review is
to minimize the risk of medication errors that might occur at the level of
prescribing and/ or drug administration.
• A medication error is any preventable error that may
lead to inappropriate medication use or patient harm.
• To prevent potential morbidity and mortality
associated with these errors,
pharmacists should systematically review the medication chart and write
annotations on the chart where the medication orders are unclear.