Aged residential care (ARC) Medication Chart ... · Aged residential care (ARC) Medication Chart implementation and training guide Page 8 of 61 . GPs ‘ Getting ready ’ phase

Aged residential care (ARC)

Medication Chart

implementation and training guide

(version 1.1)

May 2018

Prepared by

and the

Health Quality & Safety Commission

Aged residential care (ARC) Medication Chart implementation and training guide Page 2 of 61

Version 1, March 2018; version 1.1, May 2018

© Health Quality & Safety Commission New Zealand 2018

Level 9, 17–21 Whitmore Street, Wellington, New Zealand

This document is available on the Health Quality & Safety Commission website:

www.hqsc.govt.nz

Disclaimer

The information in this guide is provided to help aged residential care (ARC) facilities, their attendant

general practitioner(s) and community implement the electronic ARC Medication Chart. The

information was gathered from a number of sources. Its inclusion does not constitute or imply

endorsement by the Health Quality & Safety Commission New Zealand. While the Commission has

taken all reasonable steps to ensure the information is from reliable and reputable sources and is

accurate, it accepts no liability or responsibility for any acts or omissions, done or omitted in

reliance, in whole or in part, on the information. The Commission accepts no responsibility for the

manner in which this information is subsequently used. Users of this information must always

consider current best practice and use their clinical judgement with each patient. This information is

not a substitute for the exercise of clinical judgement by individual clinicians. The statements, views

and opinions expressed in this guide do not necessarily reflect those of the Commission.

Acknowledgements

This implementation and training guide is based on work undertaken by PharmacyPartners on

behalf of the Health Quality & Safety Commission.

The electronic charting functionality was developed pro bono by Toniq Limited, Christchurch, for

which the Commission is particularly grateful and indebted.

The Commission acknowledges the ARC facilities that participated in the various iterations of the

medication chart development. Implementation of the ARC Medication Chart will enhance the safe

and quality use of medicines in ARC settings, increasing residents’ safety and outcomes.

The Commission also thanks the people who reviewed this document and offered advice for

improvement.

Additional training and support

Additional support and training is available from PharmacyPartners

([email protected]; mobile: 021 0232 8855; phone: 04 567 8570; fax: 04 567 8571).

http://www.hqsc.govt.nz/

mailto:[email protected]


Contents

1. Document purpose 5

2. Contents of this guide 5

3. Overview of the ARC Medication Chart 6

Using the ARC Medication Chart 6

Implementing the ARC Medication Chart using this training package 7

Best practice guidelines 10

Factors to consider when introducing the new ARC Medication Chart 11

4. A guide to the ARC Medication Chart sections 13

5. Responsibilities of the care team 26

6. Creating and using the ARC Medication Chart 31

7. Aide memoire for prescribers 35

Operating principles 35

Best practice guidelines 35

Prescribing on the ARC Medication Chart 36

Stopping medicines on the ARC Medication Chart 37

8. Prescribing on the ARC Medication Chart 37

Prescribing medicines 38

Stopping medicines 38

Changing the dose of a medicine 39

9. Reading the ARC Medication Chart 40

Medicines to be administered to the resident 40

10. An important message for residents and their families and whānau 46

Why this is important? 46

What we will be doing? 46

Will residents notice anything different? 46

What do residents need to do? 46

11. Setting up Toniq 47

Setting up and using community pharmacy software to create Medicines Lists and

Signing Sheets 47

Setting up a printed chart in Toniq that meets the content requirement 48

Setting up Toniq to create the Resident Overview Sheet 51

12. Transferring information to the new chart 52

Transfer checklist (available as an editable PDF) 53

Monitoring for medication errors 53

13. ARC Medication Chart checklist 55

ARC facility checklist 55

GP checklist 55

Pharmacy checklist 56


14. Common problems 57

Appendix 1: Glossary 59

Appendix 2: Example medication chart forms provided by the pharmacy 60

Appendix 3: Example medication chart forms provided by the ARC facility 61


1. Document purpose

This implementation and training guide has been developed to support aged residential care (ARC)

facility management, general practitioners (GPs) and pharmacists to familiarise themselves with the

ARC Medication Chart and its introduction to practice, then train their staff in its use.

You can also draw on the advice and support of an expert appointed by the Health Quality & Safety

Commission to help you throughout the period of introduction.

Please note the ARC Medication Chart as described in this guide is only available through

community pharmacies that use the Toniq pharmacy software system. It is not available through

LOTS software.

2. Contents of this guide

The contents of this guide and the audiences for each section are summarised below.

Sections F

ac

ilit

y

ma

nag

ers

an

d

nu

rse

s

Pre

sc

rib

ers

Ph

arm

acis

ts

Ph

arm

acy

tech

nic

ian

s

Ca

reg

ivers

3. Overview of the ARC Medication Chart

4. A guide to the ARC Medication Chart sections

5. Responsibilities of the care team

6. Creating and using the ARC Medication Chart

7. Aide memoire for prescribers

8. Prescribing on the ARC Medication Chart

9. Reading the ARC Medication Chart

10. An important message for residents and their

families and whānau

11. Setting up Toniq

12. Transferring information to the new chart

13. ARC Medication Chart checklist

14. Common problems


3. Overview of the ARC Medication Chart

A variety of people in the sector have had concerning experiences with medication charts. This

indicates that present handwritten charting systems and processes could be improved.

Handwritten charts can be difficult to read and some doses can be misinterpreted. It can be difficult

to determine the current medicine regimen when the same chart has been changed a number of

times without being rewritten. It is sometimes easier for caregivers to work from the pharmacy-

generated Signing Sheet without referring to the resident’s medication chart for authority to

administer a particular medicine. In turn, this can result in residents continuing to receive medicines

that were to be stopped, not receiving medicines that were to be started, or receiving incorrect

doses. These things put residents and staff at risk.

Similarly, processes around medicine charting and administration can be difficult or time-consuming

to use. This diverts caregivers from looking after residents’ needs, making the experience of

residents and caregivers alike less than desirable.

A single electronically generated national chart that was easy to use and interpret was tested. It

showed that resident and staff safety could be improved by lowering the risk of medication errors

and streamlining medicine management processes.

The ARC Medication Chart has been developed to be easy to use and interpret, using a workflow

that any facility can follow.

The electronically generated ARC Medication Chart is viewed as an interim step pending the

adoption of fully integrated electronic medication management systems, which integrate into a single

system the prescribing/charting (GP, nurse practitioner (NP)), supply (community pharmacist) and

administration of medicines (ARC staff).

Using the ARC Medication Chart

Operating principles

1. All prescriber instructions to nurses and pharmacists will be legible, unambiguous and signed by

the prescriber.

2. Records at all stages of the medication prescribing, preparation and administration process will

be complete, accurate, unambiguous and legible.

3. Prescribers, nurses and pharmacists are individually responsible for keeping the residential

medication chart up to date.

4. Prescribers, nurses and pharmacists will follow the medication charting standards and processes

for their ARC facility.

Care team members’ responsibilities

Good teamwork is essential and it is important that all team members know their obligations and

roles.

5. Responsibilities of the care team outlines the roles and responsibilities of prescribers (GPs, NPs),

nurses and pharmacists in the care team. Please read and understand this section and incorporate

it into the policies and procedures used to manage medication charting in your ARC facility.


Implementing the ARC Medication Chart using this training package

The following suggested steps will help you implement the ARC Medication Chart in the facility and

use the relevant sections of this guide.

For facility management

‘Getting ready’ phase

1. Obtain agreement from the facility’s GPs and pharmacist to implement the new chart.

2. Read this guide and become familiar with the full training package.

3. Agree processes and responsibilities for operating the ARC Medication Chart system with the

GPs and pharmacists servicing the facility. This includes:

agreeing how the chart will be configured to suit local needs

identifying all policies and procedures affected by the implementation of the ARC Medication

Chart

establishing a policy to familiarise locum staff with the ARC Medication Chart and associated

procedures before beginning practice in the facility.

4. Prepare training and support material for staff using the following resources.

For nurses:




9. Reading the ARC Medication Chart.

For caregivers:


5. Train the clinical leadership group in the use of the ARC Medication Chart and the new policies

and procedures controlling its use.

‘Getting set’ phase

1. Select which residents will be transferred to the new chart, the timeframe for doing so, and in

which order transfer will occur.

2. Prepare to move to the new ARC Medication Chart by setting up and signing off policies and

procedures to:

supply the pharmacy the information they need to set up the resident’s Medicines List in the

new format

update the pharmacy on any change about the resident’s medicines, allergies and adverse

events, so they can keep the Medicines List up to date and reprint it when needed

quarantine new Resident Overview Sheets and Medicines Lists before sign-off by the GP

manage GP sign-off for quarantined Resident Overview Sheets and Medicine Lists to ensure

they enter use in the facility in a timely manner

establish the process for replacing the existing Medicines List in a resident’s medication

chart when a new Medicines List is available.

3. Train staff in the use of the chart.

4. Let residents and their families/whānau know about the introduction of the new chart and

its objectives.


GPs


1. Read:

3. Overview of the ARC Medication Chart (optional)

4. A guide to the ARC Medication Chart sections (optional)




8. Prescribing on the ARC Medication Chart.

2. Agree processes and responsibilities for operating the ARC Medication Chart system with the

facility nurses and pharmacists servicing the facility. This includes:

updating and signing off any processes and standard operating procedures affected by the

implementation of the ARC Medication Chart

establishing a policy to familiarise locum staff with the ARC Medication Chart and associated

procedures before beginning practice in the facility. To help with this, ensure the Medical

Centre’s practice nurse is familiar with the ARC Medication Chart and its use so they can

guide and support locums. Consider getting input from the ARC facility for this step.

3. Prepare training and support material for practice staff associated with medication charting using

the following resources:

For practice nurses:






1. Establish processes with facility nurses for signing off quarantined Resident Overview Sheets

and Medicines Lists to ensure they enter use in the facility in a timely manner.

2. Train any necessary staff (eg, practice nurses and locums) how to use the ARC Medication

Chart.

Pharmacist


1. Read 3: Overview of the ARC Medication Chart and become familiar with the full training

package.

2. Agree processes and responsibilities for operating the ARC Medication Chart system with facility

nurses and the GPs servicing the facility.

3. Update and sign off any processes and standard operating procedures affected by the

implementation of the ARC Medication Chart. This should cover:


receiving resident information from the care facility to support preparing new Medicines Lists

for individual residents

creating Medicines Lists and Signing Sheets, and providing them in a timely fashion to the

care facility

reconciliation processes to support the initial preparation of Medicines Lists for residents

maintaining and updating Medicines Lists when requested or as the resident’s medicine

regimens change

training locum staff in the medication chart system and associated procedures before

beginning practice in the facility.

4. Prepare training and support material for staff involved using the following resources:

For pharmacists:


4. A guide to the ARC Medication Chart sections (optional)





11. Setting up Toniq.

For pharmacy technicians:



11. Setting up Toniq.


1. Set up the Medicines List in the community pharmacy software.

2. Train necessary staff, including locums, in using the ARC Medication Chart and the processes

that support it.


Best practice guidelines

Implementation issue Guideline

ARC Medication Chart content

Chart components The ARC Medication Chart comprises:

a form summarising clinical parameters that are relevant

to the resident’s safe use of medicines

a list of the medicines the resident is currently receiving

together with their dosage, frequency of administration

and any other instructions needed for safe use

an administration record that documents the

administration of individual doses and any relevant

events relating to administration.

Medicine naming Record each medicine on a resident’s medication chart by generic name unless the prescriber and ARC facility considers resident safety demands an individual medicine is recorded by trade name.

Dosage form image and description provision1

Nurses and caregivers find images and descriptions of individual medicine dosage forms helpful for safely managing and administering residents’ medicines. However, changes in subsidised products may cause an unacceptable level of Medicines List replacement if images and descriptions are included in the Medicines List.

When dosage form images are used, if there is a significant time gap before the quarantined new Medicines List is signed off by the prescriber, it is important to develop a process to highlight to care staff changes in appearance when the subsidised medicine changes. For example, a sticker could be attached to the resident’s medication pack alerting care staff to the brand change.

Medicine dosage form images and descriptions could be made available to care staff in the form of a glossary of all the medicines in use in the facility. File this document in the medication chart folder used during medicine rounds. The pharmacy needs to update it monthly.

Medicines Order and Verbal Medicines Order forms

Archive all Medicines Lists when an updated, reprinted, signed Medicines List is placed in the resident’s record.

Process issues

Delay between charting and availability of the current medication chart

GPs, nurses and pharmacists agree processes that streamline the updating and signing off of ARC Medication Charts so there is minimum delay. They agree a maximum acceptable sign-off delay and monitor performance against that, while working together to reduce it.

1 Not all community pharmacies subscribe to the Toniq medicines images library, so they may not be able to offer this

service.


Factors to consider when introducing the new ARC Medication Chart

1. View the implementation of the new ARC Medication Chart together with the processes

associated with its use. Introducing the chart into a facility’s and pharmacy’s practices without

updating the chart management processes would be unsafe and likely to reduce the benefits of

moving to the new chart. The facility’s written policies and procedure may need to be updated to

reflect changes in the chart management process. Complete this before introducing the new

ARC Medication Chart.

2. Nurses, doctors and pharmacists may underestimate the importance of process review and

updating as a critical factor for success. In particular, they may underestimate the importance of

testing each process step in detail and adapting it, when necessary. Further, this process should

be repeated, as an initial review is unlikely to identify and eliminate all process issues.

Participants need to apply quality improvement and plan, do, study, act (PDSA)2 principles to the

project.

3. The facility, pharmacy and doctor need to agree common objectives for the new chart project.

They must establish a shared understanding of the processes associated with chart use in each

of their disciplines so sound decisions are made and all practitioners are committed to them. If

practitioners do not share common objectives and understandings, their actions will create

friction points that may make the overall chart management system less efficient and increase

the risk of medication errors.

4. It is important to build confidence in the chart amongst practitioners and facility staff at every

stage of the process. In particular, identify known risks and design a process that either prevents

them occurring or minimises risk. There may need to be flexibility in the way the chart is

implemented in a facility so the practitioners are confident in using it. Investigate any issues and

deal with them promptly to remove uncertainty about the new chart. This will improve resident

and practitioner safety and the overall management of medicines in the facility.

5. Move all residents to the new chart as quickly as possible while recognising the extra workload

and avoiding overburdening key staff members, which may jeopardise the change process.

6. Leaders of the change must be determined and resolute. They must support the change by

working as a cohesive multidisciplinary team across the three professional groups managing

medicines in the facility.

7. Changing charts and the associated processes are likely to reveal limitations in the way some

staff adapt to the change and adhere to processes. The change may be accompanied by an

increase in the number of errors as existing ways of working might be disrupted. Be prepared to

mitigate for this effect.

8. The Resident Overview Sheet has coloured sections, but there is no loss of information when

faxing these sheets.

9. Verbal Medicines Order sheet – verbal orders must only be used as permitted by the facility’s

policies and procedures. If a medicine is to continue, the pharmacy will move the medicine to the

appropriate section of the ARC Medication Chart (eg, regular or PRN section) and reprint the

chart for sign-off. Do this as soon as possible.

10. Reprinting the chart – the chart needs to be legible and uncluttered (eg, with minimal

discontinued medicines). Therefore, reprint it at appropriate times to reduce the risk of

medication error. The facility, pharmacy and prescriber need to establish a reprinting

policy/procedure. The policy should be flexible enough for nurses and prescribers to ask for a

2 See www.ihi.org/resources/Pages/HowtoImprove/default.aspx.

http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx


chart reprint when they feel it is needed. (See 14: Common problems, point 3, Reprinting the

chart workload).

The pharmacy should consider changing its sign-off procedures so the pharmacist signing

dispensed medicines out to the facility also checks if the existing chart needs to be reprinted

before releasing the medicines.

11. Consider developing a policy to cover the use of the Resident Overview Sheet. Every resident

needs an Overview Sheet that is kept up-to-date, particularly after each three-month medication

review. The policy should include that each resident new to the facility must have a Resident

Overview Sheet completed as part of the admission process.

The Resident Overview Sheet uses colour enhancements as a safety feature to emphasise the

high-risk allergy and adverse reaction sections. This use of colour is an important safety feature.

Ideally, use a colour printer especially if using medication identification images.



This part of the guide will help you understand:

what each section of the ARC Medication Chart looks like

the purpose of each section

how to use each part of the section.

You may choose to enhance resident and caregiver safety by printing various sections on different

coloured paper to provide visual cues to caregivers about which type of medicine they are

administering.

Section Role Generated by and responsibility

Resident Overview Sheet Brings together information about the resident that is relevant to their use of medicines.

Created by the pharmacy using the Toniq community pharmacy management software.

The sheet is generated by the pharmacy from a facility-specific template.

The facility nurse and doctor need to complete the details not automatically populated.

Updated by the doctor and nursing staff as the resident’s circumstances change.

Regular Medicines List The resident’s current list of regular packed and unpacked medicines together with dosage instructions and medicines start and stop instructions. New or changed medicines are added to the list using the blank structured prescribing spaces at the bottom of each section.

Created by the pharmacy using the Toniq community pharmacy management software.

Printed by the pharmacy from the resident’s previous Medicines List and updated when the blank prescribing spaces are full or when requested by nursing staff.

Short Course Medicines Order

Note: available as a printable PDF

The resident’s current list of short course medicines. New medicines are added to the list when needed using the blank structured prescribing spaces at the bottom of the list. Complete courses are crossed off when finished but are retained on the list to provide history for the doctor to support management or recurrent conditions. The chart is faxed to the pharmacy each time a medicine is added.

Used by the facility doctor to prescribe a resident’s short course medicines eg, antibiotic course.

Blank Short Course Medicines Order forms are held in the facility’s medication chart folder so prescribers can access them when needed.


Section Role Generated by and responsibility

Verbal Medicines Order


Records verbal instructions if the facility allows verbal prescribing.

If the medicine is to continue, the pharmacy will move the medicine to the appropriate section of the medication chart (eg, the Regular or PRN section).

Completed by the facility nurse on receiving a verbal order from a prescriber for a resident’s medicine.

Admission Medicines Order


Medicines prescribed when the resident is admitted to the facility. The chart remains in use until the regular medicines list generated by the pharmacy is reviewed and signed off by the prescriber.

Completed and signed for by the facility doctor for new residents.

Signing Sheet Records administration of medicines.

Created by the pharmacy using the Toniq community pharmacy management software and provided with the resident’s medicines.

Resident Medication Chart Transfer Checklist


The checklist is used to make sure that all the resident’s medicines information is safely transferred from the current (old) medication chart to the new ARC Medication Chart.

Facility nurse to use when introducing the new ARC Medication Chart into their facility.

Summary

1. The pharmacy provides (through Toniq; Appendix 2):

a. Resident Overview Sheet

b. Medicines List for regular and PRN medicines

c. Signing Sheet (regular medicines)

d. PRN and/or Non-Packed Medicine Signing Sheet.

2. The facility provides (through fillable PDFs; Appendix 3):

a. Short Course Medicines Order

b. Verbal Medicines Order

c. Admission Medicines Order

d. Resident Medication Chart Transfer Checklist.

The sheets provided by the facility are available as PDFs with editable fields (to maintain the

integrity of the form layout). These PDFs can be personalised to the facility and saved to a

facility computer as a master document. Using master documents speeds up the updating of

sheets at a future date.

Facility personalisation can include:

facility’s name

facility’s address


facility’s other contact details

prescriber’s name

prescriber’s address

prescriber’s registration number or other identifiers as appropriate.


Resident Overview Sheet section

Facility name and address

Pharmacy name and contact

details

GP name and contact details

Resident’s details

Resident’s allergies record

Resident’s adverse

reactions record

Record of important issues

affecting the resident’s use of

medicines

Record of previous reviews of the resident’s

medication

Resident’s photo

Key points:

1. Initiated by the pharmacy. This sheet provides an overview of the factors affecting the resident’s use of

medicines. The sheet is printed by the pharmacy for each resident, and contains details on the

resident, the care home, the pharmacy and the doctor. The nurse and doctor must complete the

remaining details.

2. It must be signed off by the prescriber before it is used.

3. Whenever new allergies or adverse reactions are added to the Resident Overview Sheet, it must be

sent to the pharmacy for adding to the Medicines List.

4. Use this form to record when a medication review has been completed. After the review, send the form

to the pharmacy. The pharmacy needs this information to generate new three-month prescriptions for

the doctor to sign.

5. The pharmacy has the option to scan and save completed sheets into Toniq to make the sheet easily

accessible for future printing (see the Toniq user manual).

Record of all the resident’s medical

conditions (eg, COPD, diabetes,

hypertension, osteoporosis)


Medicines List, section 1 of 4 – regular medicines packed


Resident’s allergies and

adverse reactions

Details of regularly

administered medicines the

resident is receiving

Blank section to

prescribe a new

regularly

administered

medicine

Key points:

1. This section is used to chart the resident’s regular and PRN medicines.

2. Prepared by the pharmacy from either the resident’s Admission Medicines Order or the previous

Medicines List.

3. It must be signed off by the doctor before it is used.

4. The doctor or nurse asks the pharmacy to prepare an updated list when all the blank prescribing

spaces for either regular or PRN medicines are filled, or on reaching a defined minimum number of

blank prescribing spaces in any section of the chart.

5. If the medicines are prescribed inadvertently in the wrong chart section, the pharmacy should

automatically place the medicine(s) in the correct section in the chart and reprint the chart.


Medicines List, section 2 of 4 – regular medicines packed and non-

packed

Blank section to prescribe a new

regularly administered

medicine

Key points:


Medicines List.







Details of regularly

administered medicines that

are not contained in the medicine

pack


non-packed regularly

administered medicine


Medicines List, section 3 of 4 – PRN medicines


PRN administered

medicine

Key points:


Medicines List.







Details of PRN administered

medicines that are not contained in the medicine

pack


Medicines List, section 4 of 4 – regular medicines packed, with medicine

images

Key points:

1. Not all pharmacies have the computer functionality to print medicine images. This needs to be agreed

with the pharmacy.


Medicines List.







Image of the medicine to help

identification when

administering the medicine

This example sheet is provided to support those

facilities that decide to use a chart containing images of the

medicines

Not all pharmacies have

the computer functionality to print images.

This needs to be agreed with the

pharmacy.



Key points:

1. Used to chart the resident’s short course medicines.

2. Used and signed off by the prescriber.

3. Each medicine must be signed off by the prescriber before the medicine can be administered.

4. Completed short courses will have a line drawn through them and the date and signature filled in.

5. The prescriber prescribes a new medicine by completing the medicine line. If all the prescribing

spaces are full, start a new sheet.

6. Fax the sheet with new medicine orders to the pharmacy to supply the medicines.


GP’s details

Date this order was started

Blank space to prescribe new short course medicines




GP’s details

Blank space to record a verbal order to start a new medicine

Key points

1. This section is used to record a resident’s verbally ordered medicines.

2. Prepared by the nurse receiving the verbal order, witnessed by another facility staff member to verify

the record is correct, and signed-off by the prescriber.

3. It must be signed-off by the prescriber within the time required by the facility’s verbal order policy.

4. A new Verbal Medicines Order must be started every time a new verbal order is received.

5. If the medicine is to continue, the pharmacy will move the medicine to the appropriate section of

the medication chart (eg, the regular or PRN section), and generate a prescription for the prescriber

to sign.


Signing Sheet, section 1 of 2 – Regular packed medicines

Resident’s

details

Summary of the

regular

medicines the

resident is

receiving,

including

instructions and

prescription

numbers

Daily record of

each medicine

administration to

the resident

Codes to be

used in the

administration

record when a

medicine is not

given or taken

Key points:

1. This section is used to record the administration of individual doses of a resident’s medicines.

2. Note the actual layout of the Signing Sheet may differ slightly from this example, depending on how the

pharmacy configures its computer software.

3. Prepared by the pharmacy and provided with each new supply of medicine for the resident.

4. Used to record each administration of medicine to the resident.


Signing Sheet, section 2 of 2 – PRN and/or non-packed medicines


Record of each administration of

the PRN medicine to the

resident

Name and strength of the PRN medicine

Key points:

1. This section is used to record the administration of individual doses of a resident’s medicine.

2. The pharmacy provides blank copies for each resident receiving PRN medicines.

3. The nurse records the name of each PRN medicine prescribed for the resident.

4. Caregivers record each time the PRN medicine is administered to the resident.




GP’s details

Blank space to record details of a medicine the

resident is receiving, its

dose and administration

Key points:

1. This section is used to record all the medicines the resident is receiving on admission to the facility.

It is replaced by the Medicines List as soon as the prescriber signs off the Medicines List.

2. Completed and signed off by the prescriber when the resident is admitted to the facility.

3. Faxed to the pharmacy when completed. The pharmacy provides the medicines and prepares a

Medicines List and Signing Sheet.

4. Used as the resident’s chart until the Medicines List is signed off by the doctor.



This describes the responsibilities nurses, GPs/prescribers and pharmacists supporting the facility when initiating and maintaining medication charts.

Read also 12: Transferring information to the new chart and 13: ARC Medication Chart checklist.

Care team members

Setting up Admitting new patients to the facility Maintaining and updating charts

Prepare the Resident Overview Sheet and Short Course Medicines Order

1. If facility policy permits, transcribe relevantinformation from the resident’s medicationchart to the Resident Overview Sheet foreach resident.

2. Ask the GP to transcribe the resident’sactive short course medicines to a newShort Course Medicines Order.

3. Quarantine the Resident Overview Sheetand Short Course Medicines Order to besigned off at the GP’s next visit.

4. When the quarantined documents aresigned off by the GP, use them as theresident’s medication chart and archive theprevious medication chart.

When the new Medicines Lists are received from the pharmacy:

1. Check the Medicines List against theregular and PRN medicines sections of theresident’s current chart.

a. If correct, quarantine the documentfor GP sign-off at the GP’s next visit.

b. If problems are found, refer themback to the pharmacy for correction.

When the resident is admitted, if the GP is not in attendance:

1. Provide the resident’s current medicationlist or prescriptions from their previous GP,or hospital, or previous pharmacy to thepharmacist so a Medicines List can be setup.

2. Check the Medicines List and SigningSheet against the regular and PRNmedicines sections of the resident’smedication chart. Add the Signing Sheet tothe resident’s medication chart.

a. Where there are no problems withthe Medicines List, quarantine theMedicines List for GP sign-off at theGP’s next visit.

b. If problems are found, refer themback to the pharmacy for correctionand return.

3. Check the medicines against the AdmissionMedicines Order and the Short CourseMedicines Order (if one has beengenerated by the GP).

4. Set up the resident’s medication chart withthe chart components prepared and signedoff by the GP.

Managing resident hospitalisations or referrals to specialist care

1. When a resident is hospitalised or referredfor specialist care, ensure a copy of theentire medication chart accompanies theresident.

2. Ensure any medicines prescribed byexternal prescribers are added to themedication chart and signed off by the GP,and provide the updated chart to thepharmacist.

Initiating a reprint of the Medicines List

1. Ask the pharmacy to reprint a resident’sMedicines List if:

a. nurses or caregivers find aresident’s Medicines List difficult tounderstand

b. there are numerous crossings out

c. there are no free prescribingsections available in the regularmedicines section of a resident’sMedicines List



2. When the Medicines List is signed off bythe GP, add it to the resident’s medicationchart and archive the previous medicationchart.

5. Send the pharmacy a copy of the ResidentOverview Sheet, Admission MedicinesOrder and Short Course Medicines Order (ifrequired).

When the resident is admitted when the GP is in attendance:

1. Set up the resident’s medication chart withthe chart components prepared and signedoff by the GP.

2. Send the pharmacy a copy of the ResidentOverview Sheet, Admission MedicinesOrder and Short Course Medicines Order (ifrequired).

3. Check the medicines against the AdmissionMedicines Order and the Short CourseMedicines Order (if one has beengenerated by the GP).

4. Check the Medicines List against theAdmission Medicines Order.

a. Where there are no problems,quarantine the Medicines List for GPsign-off at the GP’s next visit.


d. there are no free prescribingsections available in the PRNmedicines section of a resident’sMedicines List.

2. Mark the resident’s current Medicines Listwith a coloured3 sticker to indicate it isbeing reprinted.

When a new Medicines List is received from the pharmacy:

1. Check the Medicines List against theregular and PRN medicines sections of theresident’s old medication chart.

a. Where there are no problems,quarantine the document for GPsign-off at the GP’s next visit.


2. When the updated Medicines List is signedoff by the GP, add it to the resident’smedication chart and archive the previousMedicines List.

3 The colour of the sticker used will be recorded in the relevant operating procedure.



5. When the Medicines List is signed off bythe GP, add it to the resident’s medicationchart and archive the Admission MedicinesOrder.


Pharmacist


Prepare the Resident Overview Sheet

1. Print a Resident Overview Sheet.

2. Provide the new resident Medicines List tothe facility nurse in an envelope marked‘Medication charts quarantined forprescriber sign-off’.

Initiating Medicines Lists for the facility’s residents

1. Prepare a Medicines List covering regularand PRN medicines for each resident in thecurrent medicine packing run from theexisting patient regimen held on thepharmacy’s records.

2. Provide the new resident Medicines List tothe facility nurse in an envelope marked‘Medication charts quarantined forprescriber sign-off’.

3. Repeat steps 1 and 2 with each medicationpacking run until new Medicines Lists havebeen created for all residents.

Correcting a Medicines List

1. Make any corrections for a residentidentified by the nurse or GP.

2. Provide the updated resident MedicinesList to the facility nurse in an envelopemarked, eg, ‘Medication chart for [Mr/MrsX] quarantined for prescriber sign-off’.

When the pharmacy receives information about a newly admitted resident:

1. Establish a resident record from detailsprovided in the Resident OverviewSheet, Admission Medicines Order andShort Course Medicines Order (if onehas been generated by the GP).

2. Prepare the medicines for the resident.

3. Prepare the resident’s Medicines Listfrom the information provided by thefacility.

4. Prepare the resident’s Signing Sheet.

5. Provide the facility with the medicinesand Signing Sheet.

6. Provide the new resident Medicines Listto the facility nurse in an envelopemarked, eg, ‘Medication chart for[Mr/Mrs X] quarantined for prescribersign-off’.

7. Prepare prescriptions for GP sign-offand give them to the GP.

Reprinting a Medicines List

1. The pharmacy is to reprint a resident’sMedicines List if:

a. the facility’s nurse requests a reprintedchart

b. there are numerous crossings out

c. there are no free prescribing sectionsavailable in the regular medicinessection of a resident’s Medicines List

d. there are no free prescribing sectionsavailable in the PRN medicines sectionof a resident’s Medicines List

e. the brand or appearance of a medicineon the Medicines List changes (wherethe care team have agreed to providemedication images on the MedicinesList).

2. Provide the new resident Medicines List to thefacility nurse in an envelope marked, eg,‘Medication chart for [Mr/Mrs X] quarantined forprescriber sign-off’.


GPs


When requested by the facility’s nurse:

1. If facility policy requires, transcriberelevant information from the resident’smedication chart to the Resident OverviewSheet for the resident.

2. If facility policy requires, transcribecurrently active short course medicinesfrom the resident’s medication chart to theShort Course Medicines Order for theresident.

3. Review each Resident Overview Sheetand sign it off as a correct record of theresident’s situation.

4. Review each resident’s Medicines List andsign it off as a correct record of theresident’s regular and PRN medicinesregimen.

5. Review each resident’s Short CourseMedicines Order and sign it off as acorrect record of the resident’s shortcourse medicines regimen.

When the resident is admitted:

1. Complete the Resident Overview sectionof the resident’s chart, recording knownallergies, adverse reactions and otherfactors affecting medicines use.

2. Fill in an Admission Medicines Order forregular and PRN medicines and sign it offOR check the Medicines List preparedfrom a reconciled current medications listand sign it off.

3. Fill in a Short Course Medicines Order forany short course medicines required andsign it off.

When the resident’s new prescriptions are received from the pharmacy following a regular medication review:

1. Sign off the prescriptions for the residentand return them to the pharmacy.

When the resident’s updated Medicines List is presented for sign-off:

1. When asked by the facility’s nurse, reviewthe updated Medicines List and sign it offas a correct record of the resident’sregular and PRN medicines regimen.

When the resident’s Medicines List is received from the pharmacy:

1. When asked by the facility’s nurse, reviewthe replacement Medicines List and sign itoff as a correct record of the resident’sregular and PRN medicines regimen.



Read this section with 8. Prescribing on the ARC Medication Chart.

It provides process flow diagrams for creating and using the ARC Medication Chart under three

scenarios:

1. Creating new ARC medication charts for all residents.

2. Using the new ARC Medication Chart to manage residents’ medicines.

3. Creating an ARC Medication Chart for a newly admitted resident.


Scenario 1: Creating new ARC Medication Charts for all residents

(to transition to the new chart)


Scenario 2: Using the new ARC Medication Chart to manage

residents’ medicines


Scenario 3: Creating an ARC Medication Chart for a newly

admitted resident



Operating principles

All prescriber instructions to nurses and pharmacists will be legible, unambiguous and signed by

the prescriber.

Records at all stages of the medication prescribing, preparation and administration process will

be complete, accurate, unambiguous and legible.

Prescribers, nurses and pharmacists are individually responsible for keeping the ARC

Medication Chart up to date.

Prescribers, nurses and pharmacists will follow the medication charting standards and processes

for their ARC facility.

Best practice guidelines

ARC Medication Chart content

Chart components 1. A Resident Overview Sheet recording medicines-related factors andreview dates.

2. A current list of the resident’s medicines and instructions for their safe use(Medicines List).

3. A record of the administration of individual doses (Signing Sheet).

Medicine naming Medicines are prescribed generically unless the prescriber and ARC facility

decide trade (brand) name prescribing for specific medicines is required for

resident safety.

Medicine image and

description

provision4

1. Medicine images and descriptions are helpful to nurses and caregivers.

2. Some pharmacies have the functionality to print images of the medicinesin the regular, non-packed and PRN sections of the Medicines List. Thecare team needs to agree if medicine images are going to be provided onthe Medicines List.

3. However, frequent changes in funded medicines can cause anunacceptable level of Medicines List replacement if images anddescriptions are included in the Medicines List.

4. If medicine images are not provided on the Medicines List, then medicineimages and descriptors could be made available to ARC facilitycaregivers in the form of a glossary of all the medicines in use in thefacility. This document should be filed in the medication chart folder usedduring medicine rounds and updated monthly by the pharmacy.

4 Not all community pharmacies subscribe to the Toniq medicines images library, so they may not be able to offer this

service.


Name and dose form in capitals

Number of doses and

time when they are

administered

Maximum

daily dose

Use of medication chart components

Admission

Medicines Order and

Verbal Medicines

Order forms

All Medicines Lists must be archived when an updated, reprinted, signed

Medicines List is placed in the resident’s record.

Process issues

Delay between

charting and

availability of the

current Medicines

List

GPs, nurses and pharmacists agree processes that streamline the updating

and signing off of the Medicines List so there is minimum delay. They agree a

maximum acceptable sign-off time period and monitor performance against

that, while working together to reduce it.

Prescribing on the ARC Medication Chart

Use the correct section of the chart to prescribe a new medicine.

Prescribe for newly admitted residents using the Admission Medicines Order form: tick Regular

or PRN as appropriate.

Fill in all sections.

For strength: do not use leading or trailing zeros.

For strength units: write ‘g’ for gram and ‘mg’ for milligram, but write ‘microgram’ and ‘nanogram’

in full; for liquids, strength per standard volume in mL.

Route Indication

Strength Strength

unit


Cross through

the discontinued

entry

Record the stop

date and sign

Cross through

the discontinued

entry

Record the stop

date and sign

Stopping medicines on the ARC Medication Chart

All types of medicines are stopped in the same way.

Printed entries

Handwritten entries

A Doctor14/6/15



Prescribing medicines

The ARC Medication Chart contains the following sections.

Regular medicines in the regular medicines section.

PRN medicines in the PRN medicines section.

Short course medicines in the Short Course Medicines Order section.

For a new resident, use the Admission Medicines Order. Indicate whether an admission

medicine is regular or PRN by ticking the appropriate box.

Use the correct section of the chart to prescribe a new medicine.

Indicate the reason the

medicine is prescribed Indicate the route Record the name and

dose form of the

medicine in CAPITAL

LETTERS

Record the strength of the dosage form.

When prescribing:

avoid leading zeros (eg, 0.5 mg should

be written as 500 microgram) unless a

leading zero is unavoidable

do not use trailing zeros (eg, write 30

mg as 30 mg not 30.0 mg)

for oral liquids, record the strength in

terms of the amount of medicine

present in a standard volume of liquid

(eg, for amoxicillin 125 mg/5 mL).

Record the maximum

daily dose

Indicate when doses are to be

administered and the number of

dose forms to be administered at

that time.

To avoid confusion, circle

both the time and the amount

of medicine to be

administered to draw

attention to these

instructions.

For oral liquids the dose

should be recorded in terms

of the number of mL to be

administered.

Record the strength unit in the strength unit box:

Write microgram and nanogram in full to avoid confusion

with mg.

For oral liquids, lay out strength information like this following

the strength description on the medicine label.

Strength Strength Units

125 mg/5 mL


Cross through the

discontinued entry

Record the stop date

and sign

Cross through the

discontinued entry

Record the stop date

and sign

Stopping medicines

Printed entries

Handwritten entries

For convenience, only the entry for a PRN medicine is shown here. Regular medicines and short

course medicines are stopped in the same way.

Changing the dose of a medicine

To alter or change a medicine, stop the original order completely (as above) and prescribe on a new line.

A Doctor14/6/15



This guide will help ARC facility caregivers understand how to read the various sections of the ARC

Medication Chart and know when a medicine has been stopped.

The sections of the chart share many common features to make it easy to read. It is important to

understand the additional information in the PRN medicines, Short Course Medicines Order and

Admission Medicines Order sections.

Medicines to be administered to the resident

Medicines List – regular medicines

Information about the resident’s regular medicine can be presented in two forms: printed and

handwritten. Handwritten entries have been added after the list was printed.

Printed entries

The name and

strength of the

medicine, and the

route it is given by

The reason the resident is

taking the medicine

The amount of the medicine and the time it is to be given to

the resident

Instructions for giving the medicine to the

resident

Known

allergies

Prescriber’s signature to confirm stop instructions

The date when the

medicine is to stop

Prescriber’s signature

confirming the start instruction

The date when the

medicine starts


Handwritten entries

SOLID DOSAGE FORMS

Liquid dosage forms

The reason the resident is taking the medicine

The route the medicine is given by

Start date



Start date

The name of the medicine and dose

form (eg, liquid, tablet)

The amount of the medicine and the time it is to be given to the resident

The strength of the medicine

Special instructions for giving the medicine The units the strength

of the medicine is measured in (eg, mg,

g, microgram)

The amount of the medicine and the time it is to be given to the resident. The size of the dose is recorded as

the number of mL of liquid to be administered


Note: strength per 5 mL

Special instructions for giving the medicine

The name of the medicine and dose

form (eg, liquid, tablet)


Medicines List — PRN medicines

Information about the resident’s PRN medicine can be presented in two forms: printed and handwritten. Handwritten entries are added after the chart was printed.

Printed entries

Handwritten entries



The name, strength and dose form of the medicine (eg, tablet, liquid)

Instructions for giving the medicine

The amount of the medicine to be given to the resident if not included in the instructions (the amount is

included in the instructions in this example)

Instructions for giving the medicine


The route the medicine is given

by

Start date

The amount of the medicine to be given to the resident if not included in

the instructions


The maximum amount of medicine to be given in a day

The name of the medicine and dose form (eg, liquid, tablet)

Start date

A Doctor31/5/15



Active entries

Short course medicines the resident is taking will always be handwritten.

Stopped entries

When a short course medicine has been completed, the entry will have a cross through it to indicate

it is no longer being administered.

Cross through the chart entry


The route the medicine is given

by

Start date

The date when the medicine is to stop

The units the strength of the medicine is measured in (eg, mg, g, microgram)


Special instructions about how the medicine is given to the resident

The name of the medicine and dose form (eg, liquid, tablet)

The amount of the medicine and the time it is to be given to the resident



The Admission Medicines Order is used for a short time after the resident is admitted to the facility.

Information on it is always handwritten.

The reason the resident is taking

the medicine

The route Start date Whether the medicine is

regular or PRN

The name of the medicine and the dose form (eg, tablets, liquid)

Special instructions about how the medicine is given to the resident

The maximum amount of medicine to be given in a day if the medicine is PRN

The amount of the medicine and the time it is to be given to the

resident


The date the medicine is to stop

The units the strength of

the medicine is measured in (eg, mg, g, microgram)


Cross through the discontinued entry Stop date and GP/NP signature

Stop date and GP/NP signature Cross through the discontinued entry

Medicines that have been stopped

Medicines that have been stopped are clearly marked with a cross through them and a stop date.

This applies to both printed entries and handwritten entries.

Printed entries

Handwritten entries

For convenience, only the entry for a PRN medicine is shown here. Regular medicines and short

course medicines are stopped in the same way.

A Doctor14/6/15


10. An important message for residents and their

families and whānau

(This form is available as an fillable PDF that can be printed, see Appendix 2)

Very soon << name of facility >> will be introducing a new ARC Medication Chart that will

be better for residents and staff than the chart currently in use.

Why this is important?

Most residents in our rest home need medicines to keep them well. Managing those medicines in

the rest home is complex. The medication chart that records the medicines a resident is currently

taking and the doctor’s instructions for using them is a very important part of the process. It ensures

residents’ medicines are effective and residents are safe.

Because it is so important, we are always looking for ways to improve how we manage residents’

medicines.

What we will be doing?

We will be introducing a new medication chart. This new chart has been developed by the Health

Quality & Safety Commission for use in many rest homes across

New Zealand.

The new medication chart is designed to be easier to fill in, and work from, than present charts in

our day-to-day operations. It has the support of the nurses, caregivers, doctors and pharmacists

who care for residents in our rest home.

Will residents notice anything different?

It is likely residents will notice very little difference when the new medication chart is introduced.

The most likely thing they will see is that the chart their medicines are recorded on will look slightly

different from the chart they are used to. The new chart won’t require doctors to change the

medicines residents are taking. That said, as is usual, individual residents may find their medicines

change from time to time as their health changes.

What do residents need to do?

Residents don’t need to do anything different as the new chart is brought in. Caregivers will continue

to ask residents to take their medicines as before.

If you have any concerns about the new medication chart, please let one of the nurses know.


11. Setting up Toniq

(To create a Medicines List, Signing Sheet and Resident Overview Sheet)

Additional functionality has been added to Toniq to allow pharmacists to set up and generate

Medicines Lists as part of the process of supplying medicines to an ARC facility. The information

below describes how to set up the software to generate lists meeting the requirements for the ARC

Medication Chart.

Setting up and using community pharmacy software to create Medicines

Lists and Signing Sheets

The sections of the printed ARC Medication Chart are:

Resident name

Resident National Health Index (NHI) number

Resident address

Resident date of birth (DOB)

Prescriber name and address

Prescriber registration number (Medical Council of New Zealand (MCNZ) or other Registration

Authority equivalent)

Allergies and adverse reactions (described at present as intolerances)

Date the chart was printed

Regular medicines section

Short course medicines section

PRN (as required) medicines section

Medicine name and dosage form

Medicine strength, and strength units

Medicine dose and the time(s) it is to be administered

Route of administration

Name and address of the community pharmacy preparing the printed chart

Medicine start date

Prescriber signature for each medicine

Medicine stop date space

Prescriber signature space to authorise the stop date

Medicine description

Medicine photograph

Resident gender

Resident room number

Facility phone and fax numbers.

Note: A record of medicine review outcomes is not required on the printed chart. Please do not provide it.


Setting up a printed chart in Toniq that meets the content requirement

Note: Further assistance in setting up Toniq is available from Toniq Support (03 341 0195 during

business hours; fax 03 341 0196).

1. Printed chart options required to meet mandatory requirements

The following three screenshots record the Toniq dosepack chart settings needed to create a printed chart meeting the mandatory requirements outlined above.

To access these option screens, follow these commands from the main Toniq screen:

5. Dosepacks/Charts

7. Administration

6. Edit dosepack chart types

Note: Pharmacy can edit an existing chart type OR add a new one. The latter is recommended if

the pharmacy services more than one ARC facility and the new standards are not being

implemented at the same time across all facilities.

Press spacebar to see the current chart types setup and possibly select one to edit.

If only the default chart type is listed, editing this will affect all charts produced in

Toniq regardless of facility. Only select this if you know what you are doing!

If there are other chart types listed it may be appropriate to select one of these

and edit it, but again if you don’t know for sure that this is used by the relevant

ARRC facility that is changing to the new standards do NOT select it.

OR Add a new chart type (recommended)

Press F3 ADD to add a new chart type

Press F10 Other and select Row layout default settings

First dosepack chart option screen


Second dosepack chart option screen

Third dosepack chart option screen


In the Message lines, insert:

1. ‘Use blank prescribing spaces to add new medicine or change existing medicines’; and

2. ‘Fax the chart to the pharmacy each time a new medicine is added, changed or reviewed’, to

prompt the ARC facility staff to provide the printed chart to the pharmacy even if the medicines

on it are to be continued unchanged. This ensures the pharmacy has full information about the

outcome of a medicines review.

2. Printed chart sections required to meet mandatory requirements

The following two screenshots record the Toniq dosepack chart settings needed to create the

medicine sections in the printed chart meeting the mandatory requirements outlined above.

To access these option screens, follow these commands from the main Toniq screen:

5. Dosepack/Charts

7. Administration

7. Edit dosepack chart sections

Spacebar (to select the section to set up)

Edit the name of each section and order to follow the names and sequence appearing below using

the appropriate edit screen.

Note: The chart sections already set up may be used for other facility charts. If you are not changing

all institutions to the new standards now, add new chart sections rather than editing existing ones. If

you do need to add new ones it will be important to check that Rx’s in packs for the relevant facilities

are moved to the appropriate setups.

Required chart sections and sequence

Chart section edit screen – setup for each of the five sections is shown:


3. Recording information to appear on the printed chart

The prescriber needs to record the following additional information on the Admission Medicines

Order and the Verbal Medicines Order:

indication

route.

Record this information on the medicine label to ensure the information appears on the printed chart.

Setting up Toniq to create the Resident Overview Sheet

In Toniq, some pharmacies use a short-form facility name to suit the pharmacy processes, rather

than using the facility’s actual full name. The facility and the pharmacy should agree the preferred

facility name to appear on the facility’s Resident Overview Sheets.

The preferred facility name should be set up in a separate Resident Overview Sheet template for

each facility. If a separate template is set up, you do not have to enter the facility name each time a

Resident Overview Sheet is printed.

1. Setting up a separate template for each facility

The TQ Toniq templates cannot be edited, but a pharmacy template can be created as a

copy of the TQ template.

Start at the Other/Templates menu, Add, F10 – Copy from existing template.

If you service, for example, two facilities, create two templates and title them appropriately.

Add the agreed facility name to each template.

2. Setting up the Doctor field

The Resident Overview Sheet picks up the ‘Usual Doctor’ field in Toniq.

If the ‘Usual Doctor’ is not to be printed on the sheet (for example, if it is known that another

doctor will be signing the sheet off), the ‘Usual Doctor’ field in Toniq must be updated before

printing the template for a patient.


12. Transferring information to the new chart

When a printed chart is created for the first time, to prevent transcription errors, pay close attention

to the need for close liaison and a formal medicine reconciliation process.

To formalise this process, use the following process flow:

Use the transfer checklist (below) to make sure each critical step is completed and no medicines are

missed off the new chart.

Step 1. Initiated and filled in by the pharmacy; reviewed by the facility.

Step 2. The new chart is populated with the resident’s medicines by the pharmacy.

Step 3. The facility confirms the medicines entered into the chart are correct/as they expect.

Step 4. The prescriber confirms the medicines by signing the new chart against each

individual medicine.

Step 1 See checklist

below


below


below


below


Transfer checklist

Use this checklist to ensure the resident’s medicines information is safely transferred from the

current (old) to the new ARC Medication Chart.


Monitoring for medication errors

When new systems and processes are introduced, errors may happen unintentionally. All

medication errors and ‘near misses’ that result from the introduction of the ARC Medication Chart

should be reported, the underlying cause(s) investigated, and changes implemented to prevent

recurrence. They should be reported to the national Medication Error Reporting Programme (MERP;

https://nzphvc.otago.ac.nz/merp/report/) so any changes to the design of the chart can be looked at

and implemented nationally, if appropriate.

MERP collects and analyses voluntary reports from health care professionals of actual and near

miss medication errors occurring in primary care. Its aim is to enhance the safety of medication use

for New Zealanders by sharing information about medication errors to reduce and prevent harm.

https://nzphvc.otago.ac.nz/merp/report/


13. ARC Medication Chart checklist

ARC facility checklist

1. Identify the residents who are next due to have their medicines reviewed by the GP.

Share this list with the pharmacy so they can prepare Medicines Lists for these

residents.

2. Print and label a set of Resident Overview Sheets for these residents.

If facility policy permits, transfer all relevant information for each resident to their

Overview Sheet (eg, swallowing difficulty, falls risk and medication review dates).

3. Quarantine the completed Resident Overview Sheets for GP sign-off at the next

visit.

4. Receive the resident’s printed Medicines Lists from the pharmacy and quarantine

them for GP sign-off at the next visit.

5. Once the documents are signed off, transfer them to the resident’s medication chart

and archive earlier material.

GP checklist

As part of the setting up process for the new ARC Medication Chart, you will be asked to sign

off Resident Overview Sheets and printed Medicines Lists after reconciling them with the

residents’ existing charts.

1. If the facility’s policy does not permit the nurse to transfer any allergies/adverse

reactions or other factors affecting medicines use to the Resident Overview Sheet,

transfer this information to the sheet and validate these with your practice record.

2. Reconcile the completed Resident Overview Sheets and printed Medicines Lists

against the residents’ existing medication charts and sign them off.


Pharmacy checklist

The pharmacy needs to prepare Medicines Lists for each resident in the facility and set up the

procedures needed to replace the residents’ Medicines Lists when requested or when the pharmacy

team concludes it can no longer be used.

1. Establish the procedure by which the pharmacy creates and updates Resident

Overview Sheets.

2. Establish the procedure by which the pharmacy creates and updates Medicines

Lists.

3. Establish the procedure by which the pharmacy checks the new Medicines List

and forwards it to the facility nurse to be quarantined for GP sign-off.

4. Set up a Resident Overview Sheet template for each ARC facility that you service

in the dispensary software.

5. Set up a Medicines List template in the dispensary software.

6. Agree the patient sequence in which new Medicines Lists are to be prepared from

existing charts with the facility nurse.


14. Common problems

Potential trip-up How to avoid

1. Missed medicines administration – ‘failureto see’

When first using the new ARC MedicationChart, staff may fail to see a medicine (andso do not administer it) if it appears at thebottom of a chart page and is preceded onthe page by blank prescribing spaces (eg,if there is a separation between regularpacked medicines and non-packedmedicines such as insulin).

To give greater visibility to section breaksbetween medicine groups, some facilitiesfind it helpful to highlight the sectionheadings in the affected charts with acoloured highlighter.

When introducing the new ARC MedicationChart, we suggest the facility and pharmacyagree who is best placed to highlight thesection headings.

2. Medicines missed off the new chart

When the medicine is not transferred fromthe old chart to the new ARC MedicationChart.

Follow the process and transfer checklistdescribed in section 12.

Report any events or ‘near misses’ toMERP:https://nzphvc.otago.ac.nz/merp/report/

3. Reprinting the chart workload

Charts need to be reprinted from time totime either because new medicines havebeen added to the resident’s regimen, orthe chart itself has been damaged, worn orbecome hard to read.

Reprinting the chart imposes additionalworkload on nurses, pharmacists andprescribers to reconcile the reprinted chartagainst the existing chart (pharmacists,nurses and prescribers) and signing off thechart (prescribers).

On the other hand, reprinting a printed chartis quick and easy for the pharmacy. Thereprinted chart must be reconciled andsigned off.

The more often charts are reprinted, themore time it takes to reconcile and sign offthe new charts. These steps werepreviously hidden as part of the processundertaken by the prescriber. These stepsare now distributed amongst nurses,pharmacists and prescribers.

Reprinting the chart improves patient safetyby increasing legibility (and reducing therisk of misreading a ‘messy’ or damagedchart) and removing outdated information,providing a shorter chart.

Overall, the workload associated withreprinting the chart is smaller than theworkload associated with rewriting a chart.

The facility staff, prescriber(s) and thepharmacy must agree realistic criteria forwhen charts should be reprinted (eg, whennew medicines are added, or when thechart is damaged, worn, or hard to read).

Staff will need to accept theadditional/redistributed workload associatedwith reprinting charts, in the interests ofpatient safety.

https://nzphvc.otago.ac.nz/merp/report/


Potential trip-up How to avoid

4. Hospice and specialist prescribing

Some residents require either a specialistconsultation or care, managed through ahospice. In the initial stages of chart rollout,prescribers will not have encountered theARC Medication Chart and will not befamiliar with the use of the chart. Theymight ask facility staff for guidance on itsuse and which sections to use for newprescribing.

Briefing these prescriber groups on the useof the chart at the time the chart isintroduced to the facility is likely to becounter-productive as there may be asignificant time delay between the deliveryof the briefing and the prescriber’s firstencounter with the chart.

Failure to provide a briefing when a newprescriber starts to use the chart risksinappropriate use of the chart by theprescriber and the perpetuation of badcharting habits by other prescribers.

The facility nurses should brief prescribersnew to the ARC Medication Chart (includingspecialists and hospice prescribers) on thechart’s layout, the appropriate section formedication and the facility’s medicinesmanagement process.

Include how to accurately prescribeindividual medicines on the chart and therisks associated with charting medicines ininappropriate chart sections as part of thetraining.

Help prescribers position the newprescriptions in the appropriate section ofthe chart.

The Short Course Medicines Ordersupports the hospice regimen well, and theregular and PRN medicines prescribingspaces are suitable for specialistprescribing.

Give new prescribers a copy of theprescriber’s aide memoire on using thechart (section 7).

5. Multiple faxing of medication charts canmake sections illegible

Annotating a faxed copy of the medicationchart then faxing it back to the facilityrenders it illegible.

Do not do this.

6. The pharmacy not knowing when theresidents’ three-monthly reviews have beenundertaken

The pharmacy needs to know when thethree-monthly medication reviews havebeen completed so a new three-monthprescription can be generated for theprescriber to sign (to meet legal andclaiming requirements).

Use a Resident Overview Sheet for allresidents. When the three-monthlymedication review is completed, note thison the Resident Overview Sheet, and fax itto the pharmacy.


Appendix 1: Glossary

Abbreviation Meaning

ARC Aged residential care

GP General practitioner

LOTS A brand of pharmacy dispensing software. The LOTS system does not support this electronic ARC Medication Chart

NP Nurse practitioner

PDF Portable document format. A file format for capturing and sending documents electronically in exactly the intended format

PRN Pro re nata, which means ‘when necessary, or ‘as needed’

Toniq A brand of pharmacy dispensing software. Toniq is the only system that supports the electronic ARC Medication Chart


Appendix 2: Example medication chart forms provided by the

pharmacy

PDFs of the following forms are available on the Health Quality & Safety Commission website (in the

National Medication Chart section). The forms are provided, individualised for each resident, by the

pharmacy. They are provided as examples only, and must not be used in practice.

Resident Overview Sheet

Medicines List – blank

Medicines List – standard

Medicines List – with medicine images

Signing Sheet regular medicines

PRN and/or non-packed medicines Signing Sheet

https://www.hqsc.govt.nz/our-programmes/medication-safety/publications-and-resources/publication/3228/


https://www.hqsc.govt.nz/assets/Medication-Safety/NMC-PR/2a_Resident_Overview_Sheet_Mar18.pdf

https://www.hqsc.govt.nz/assets/Medication-Safety/NMC-PR/2b_Medicines_List_-_Blank_Mar18.pdf

https://www.hqsc.govt.nz/assets/Medication-Safety/NMC-PR/2c_Medicines_List_-_Standard_Mar18.pdf

https://www.hqsc.govt.nz/assets/Medication-Safety/NMC-PR/2d_Medicines_List_-_With_medicine_images_Mar18.pdf

https://www.hqsc.govt.nz/assets/Medication-Safety/NMC-PR/2e_Signing_Sheet_Regular_Medicines_Mar18.pdf

https://www.hqsc.govt.nz/assets/Medication-Safety/NMC-PR/2f_PRN_Non-packed_Meds_Signing_Sheet_Mar18.pdf


Appendix 3: Example medication chart forms provided by the

ARC facility

(These forms are available as fillable and printable PDFs)

Fillable PDFs of the following forms are available on the Health Quality & Safety Commission

website (in the National Medication Chart section). (The PDF maintains the integrity of the form

layout).

The facility provides these forms for each resident:




Resident Medication Chart Transfer Checklist

Resident Information Sheet – ‘An important message for residents and their families and

whānau’

ARC facilities can download the PDFs and personalise the information. The forms can then be

saved to a facility computer as master documents, which speeds up the process when updating

forms for facility residents.

Facility personalisation can include:

facility’s name

facility’s address

facility’s other contact details

prescriber’s name

prescriber’s address

prescriber’s registration number or other identifiers as appropriate.


https://www.hqsc.govt.nz/assets/Medication-Safety/NMC-PR/3a_Short_Course_Medicines_Order_FFields_Mar18.pdf

https://www.hqsc.govt.nz/assets/Medication-Safety/NMC-PR/3b_Verbal_Medicines_Order_FFields_Mar18.pdf

https://www.hqsc.govt.nz/assets/Medication-Safety/NMC-PR/3c_Admission_Medicines_Order_FFields_Mar18.pdf

https://www.hqsc.govt.nz/assets/Medication-Safety/NMC-PR/3d_Transfer_Checklist_FFields_Mar18.pdf

https://www.hqsc.govt.nz/assets/Medication-Safety/NMC-PR/3e_Resident_Information_Sheet_FFields_Mar18.pdf

Documents

Aged residential care (ARC) Medication Chart ... · Aged residential care (ARC) Medication Chart implementation and training guide Page 8 of 61 . GPs ‘ Getting ready ’ phase