Medication

Medication A. Documents pertaining to medication must be accurate and readily located. When medication is a prescribed intervention for a problem identified in the resident’s treatment plan, it must be noted as such in the treatment plan. Medication changes must be made during treatment planning meetings whenever possible. When circumstances preclude this, the changes must be reviewed for all team members’ update at the next available staffing opportunity. B. When medications are prescribed or changed, a member of the professional staff must review, with each resident’s parent/guardian, the following: 1. The name/class of medication, 2. The method of administration, 3. The symptoms targeted, 4. Possible side effects of the medication, 5. Possible long-term effects of the medication, 6. Treatment alternatives, and 7. Likely outcomes of using/not using the medication. C. When a face-to-face encounter cannot be held with a parent/guardian prior to starting a medication regimen, the "informed consent" conference must be held by telephone, with the parent’s/guardian's responses noted and dated. 1. Two (2) PRTF staff must witness the form after talking with the parent/guardian. 2. The informed consent must be signed by the parent/guardian within thirty (30) days after the telephone consent. D. Documentation must substantiate that medications have been accurately administered in accordance with the physician’s or PMHNP’s orders. Any variances must be justified in the record by medical staff. E. An instrument for monitoring medication side effects must be identified and routinely administered to each resident who is prescribed psychoactive medication upon admission, at least every sixty (60) days during his/her stay and again at discharge. F. Medication adjustment is defined as the use of a resident’s routine medication in a non- routine way to help the resident through a period of heightened stress or agitation. Medication adjustment is not considered to be a special procedure. Medication adjustments must not be sedating, must be administered orally, and must be taken voluntarily by the resident. Standing PRN orders for medication adjustments are acceptable.