East & South East England Specialist Pharmacy Services Medicines Use and Safety Division Community Health Services Transcribing
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1 East & outh East England pecialist Pharmacy ervices East of England, London, outh Central & outh East Coast Medicines Use and afety Division Community Health ervices Transcribing Guidance to support the safe and appropriate use of transcribing of medicines information for the purpose of recording administration of medicines in various health and social care environments.
2 Medicines Use and afety Division Community Health ervices Background The dictionary defines transcribing as the act of making an exact copy usually in writing. This means that there must always be an original from which the transcribed copy is made. In health care the act of transcribing is usually performed so that medical records, prescription details and other communications are available to the professionals caring for a patient. The prescriber responsible for generating the original instruction carries the legal liability for the content of that instruction. If this is then transcribed accurately and without any alteration the person making the transcribed copy does not assume that liability. This would only become an issue if inaccuracies appear as a result of the transcribing so one would expect this to be carried out without risk of transcribing errors occurring. Transcribing is not substitution as this implies changing the original for a new or amended instruction. In the context of prescribing and medication administration records this means that any competent person can transcribe the details of a prescription or a direction to administer, for the purposes of keeping accurate records of administration. This is essential in various situations ranging from carers in community administering in the patient s own home to ward staff in any acute hospital setting. The varying guidance produced by various organisations may not help as such guidance often seems to be at variance with the need to ensure continuity of care. We need to acknowledge the need for transcribing and ensure that robust systems using quality documentation with trained and competent staff operating are in place. The law Transcribing is not covered by the Medicines Act, which includes legislation to cover administration under the direction of a prescriber. This direction does not have to be in writing although good practice requires this in most situations. The minimum legal requirements are usually extended to require all medicines administration to be done as a result of a prescription, a patient specific direction or a patient group direction. There are exemptions for some health care professionals which are not part of this guidance. All health care professionals are required to keep accurate records of their activities, particular medicines administration. Furthermore as a result of improved regulation, environments such as care homes and domiciliary care services are required to keep proper records to ensure that the requirements for registration are achieved. In all situations we would therefore expect that accurate records of medication administration will be kept. This should not only include all prescribed medication but also medicines given under a PGD, homely remedies and medication self purchased and administered. uch records are also necessary to protect the organisation and the individual from civil litigation. The Patient It is essential that we remember that it is the patient s needs and safety that come first and that the patient should be included in the discussion as to how best to provide care. In many of the situations where transcribing will be necessary the medication has been supplied, and would have been taken by the patient if they were still at home. The ongoing administration could well be left to the patient to continue as a self administering patient so the patient must be involved in the decision as to who will administer medication. Only where there is genuine risk should this right be removed from the patient and when this is necessary transcribing will be required as part of this process. Transcribing Guidance Vs.1 Feb 25 th 2011 (DG) 2
3 Medicines Use and afety Division Community Health ervices Why do we need transcribing? Apart from the professional responsibility already mentioned we need to ensure continuity of care and treatment of patients, especially when they move to a new care setting. The risk created by not administering prescribed medication while waiting for a chart or MAR card to be written may well outweigh the risk created by administering the drugs from a transcribed chart. Examples would include missed insulin, anti epilepsy and Parkinson s medication. Delays in giving medication while waiting for a prescriber to appear may therefore have serious consequences. This is the subject of a recent alert from the NPA i. The CQC have also published a report which requires better process for sharing of information when patients move care settings ii. However despite these there are many settings where it is not possible for a prescriber to attend to write or rewrite medicines administration record cards so accurate transcribing of this information is an essential tool to facilitate continuity of care. The nursing and midwifery Council also acknowledge the need for transcribing in certain circumstances in the standards document iii Prescribing and directions to administer (PD) Where a prescriber is present e.g. a hospital ward, the prescriber would be expected to write the direction to administer directly onto the medication administration record chart (MAR chart). The entry should include all information necessary to allow the drug to be given in accordance with the wishes of the prescriber. (Whilst the quality of prescribing often falls short of best practise this is being addressed elsewhere). In most other environments such as care homes the prescription is generated by the GP, dispensed by a community pharmacy and the medication sent to the home. The prescriber is not usually involved in completing the MAR and in fact will often never see this document! The MAR chart will therefore be a transcription of the original prescription and this is often done by the dispensing pharmacy as part of their services to the home. The printing of the MAR charts is offered as part of the overall dispensing service and is not covered by NH core dispensing services within the community pharmacy contract. The contractor does however have a professional obligation to ensure that the information is both complete and accurate but problems may arise where medication is changed, initiated or discontinued during the routine 4 weekly cycle. Many pharmacists are reluctant to reprint a MAR chart where a simple dose change has been requested by the GP. In care situations where the patient is in his or her own home the picture is more complex. There is a greater chance that prescriptions may be dispensed at various pharmacies. MAR charts are not routinely offered to such patients and the commissioning of these services seldom includes any extra dispensing services such as MAR chart printing. The increasing use of agencies rather than directly employed social services ensures that there is great variation in the quality and use of such MAR charts in home care. The key issue is that where MAR charts are in use they must be accurate. This will require transcription but by whom and how is accuracy checked? There also needs to be acceptance that verbal confirmation may be necessary to ensure MAR charts are complete. This should be the exception but when absolutely necessary a standing operating procedure must be in place to ensure accuracy. Transcribing Guidance Vs.1 Feb 25 th 2011 (DG) 3
4 Medicines Use and afety Division Community Health ervices Implementing transcribing in practice The appendix lists a variety of situations where transcribing may be necessary. Wherever this happens the organisation should have a standard operating procedure which covers the following. When What triggers the need for a record to be transcribed Who Which member of staff can transcribe How Details of the process including which MAR chart, what evidence is required, who should double check etc What The details required for administration to continue in a safe manner Further action Who needs to kept informed, how long is transcribed copy valid for etc. ome organisations have good examples of a transcribing policy but which fail to benefit patients in full because having allowed transcribing there is an insistence that the transcribed prescription is countersigned by a prescriber before any medication can be administered. Patients may well be denied essential medication while waiting for this signature which will then become a prescription anyway with the new prescriber accepting clinical liability. A well transcribed item, double checked by another competent person, is likely to carry less risk than one that is counter signed by a stressed junior doctor who may or may not read what he or she signs. The NICE guidance on reconciliation clearly shows that reliance on junior doctors at this stage is unsafe iv. In the care sector it is most unlikely that any doctor will be available to write a chart at all. Transcribing may be the only tool possible to ensure safe and continuous care. In fact the combined weight of the NICE guidance and the CQC report would indicate that reconciliation is necessary at all times when a patient moves between care environments. Patient Group Directions (PGD) The use of PGDs presents a particular challenge if a patient changes environment while taking a course of medication supplied to the patient under a PGD. As this is not a prescription it does not authorise another individual to administer the drug but as a supply has been made under the PGD there may need to be a pragmatic approach based on patient s need to continue. e.g. to complete a course of antibiotics after entry to a care home. taff training & competencies Work has been done already which looks at this issue including North West Wales who have identified 6 competencies for nurses in their policy. The transcriber 1 Can outline the legal requirements of prescribing and has an understanding of the regulations concerning prescribing and Controlled Drugs (CDs). 2 Can outline the importance of clarity and the use of standard units Transcribing Guidance Vs.1 Feb 25 th 2011 (DG) 4
5 Medicines Use and afety Division Community Health ervices 3 Has a detailed understanding of the requirement for transcribing of inpatient charts 4 Has a detailed understanding of the requirement for transcribing on To Take Out documentation (TTO) 5 Has a detailed understanding of the requirements for transcribing on TTOs for CDs 6 Can demonstrate an understanding of the role and responsibility of Pharmacists, Accredited Nurses and Doctors with regard to transcribing However these may be best applied in an acute situation so for a more general focus the competencies may be covered by the following. The transcriber / Checker 1. Can confirm that the medication needs to be transcribed to enable continuity of care 2. Can confirm that the sources of the information are current and reliable as defined by the organisational procedures. 3. Can complete a new entry with all the required details to ensure medication can be administered in a safe manner 4. Can take appropriate action after completing the document as laid down by organisational policy In this process the legal status of the medication is not relevant as all drugs are treated the same. In the event of a CD being used this would still be covered as the CD status does not affect this process. It may be considered that extra documentation and checks may be necessary for CDs but in some environments the carers may not be aware of this status. It is sensible to ask the employee to carry out practice transcribing after training to establish competence. This could be done using fictitious details in a classroom situation or in real life situations. Conclusion There are many health and social care environments where there is a need to record administration of medication and where transcribing the details onto a medicines administration record chart will facilitate this. The act of transcribing is legal but the process must be covered by robust operating procedures and governance, which is the responsibility of the employers of the staff who transcribe. Where a third party is involved such as a community pharmacy this service should be commissioned as part of a properly managed service. In order for care to be both safe and continuous each organisation must acknowledge the role that transcribing plays and set up a structure to ensure that this is done safely and effectively, whatever the setting. Transcribing Guidance Vs.1 Feb 25 th 2011 (DG) 5
6 Medicines Use and afety Division Community Health ervices Appendix 1 Transcribing - The process All transcribed entries must be on approved documentation It is imperative that any drug entry which is transcribed is for a drug which has been confirmed as being necessary to continue Patient identifier Enter the information Current responsible prescriber required which Allergy status should include Name of drug including brand if necessary trength Formulation Dose Frequency Length of course if applicable For prn drugs reason for use, maximum dose, number of repeat doses allowed ource of evidence Copy of original prescription Discharge letter Verbal contact with prescriber GP print outs Electronic records (CR) Pharmacy records Patient notes Ask the patient / carer Clinical need Previous chart PMR printout from pharmacy Labels on the products GP printout Patient notes Agreed care plan All the above to be included in the new entry which will be signed, dated and timed by the author All the above to be checked by the witness which will be signed, dated and timed by the witness Where possible this entry will be confirmed and signed by the clinician currently responsible for the patient which will then change the entry into a valid, new prescription or PD. It is important to remember that a further supply cannot normally be made against a transcribed entry until such time as that entry has been signed by a prescriber or a separate prescription is generated. Appendix 2 Examples where transcription may be necessary. (This is not a definitive list but covers most common situations.) New admissions requiring medication while waiting for doctor to attend Acute hospital ward with regular doctor in attendance Old card is full and waiting for doctors to re-write Nurse and witness Pharmacist Witness would usually be another nurse but could be trained assistant. Pharmacists should be able to work alone. Would not normally be necessary for more than one or two doses. Transcribing Guidance Vs.1 Feb 25 th 2011 (DG) 6
7 Medicines Use and afety Division Community Health ervices New admission from acute unit arriving without appropriate chart Community hospital Hospice New admission from community Long stay patient whose MAR chart is complete New drug prescribed off site and delivered to the hospital e.g. via FP10 Nurse and witness Pharmacist This environment will vary considerably with some having little medical or pharmacy support. If a contractor supplies will they provide MAR charts and amend mid month if they do? ome rely on input from community matrons but this does not guarantee accuracy as he/she may not be familiar with all medicines being taken. In fact there will be situations where an independent prescriber should not write these cards as the drugs and conditions may be outside of their scope of practice! Verbal order (VO) to use stock drug Need VO procedure May be time limited so cannot continue without signature New admission Nurse and witness If new drug some discussion about using spare Change needed to a completed MAR chart Pharmacist may reprint but not usually until next regular supply labels. What if supplies from dispensing Dr? If VO how is this done and details transcribed to New drug prescribed chart and labels? In some areas there are delays while home Care homes with nursing Dose changed by VO contacts GP, who may not be original patient s beds GP, and wait for confirmation. New admission Change needed to a completed MAR chart enior staff New drug prescribed Dose changed by VO Care home Pharmacist may reprint but not usually until next regular supply. ome pharmacists will supply spare labels to add to chart In small homes may only be one individual on duty so admissions need to be planned. Can be a particular problem at night. taffing levels m ay be difficult so changes may only get checked in larger homes. In some areas there are delays while home contacts GP, who may not be original patient s GP, and wait for confirmation Transcribing Guidance Vs.1 Feb 25 th 2011 (DG) 7
8 Medicines Use and afety Division Community Health ervices New service user Key worker If pharmacist involved how will this be Current service user on a May have pharmacist support to commissioned? We need to avoid unnecessary Patients being cared for in monthly basis either print or to check use of MD etc. Printing of MAR charts needs to domestic environment New drugs May have DN involvement be a standalone service. Also need to look at use Changed doses May get GP to check of spare labels in this context. New transfers in enior nurse Is printing likely to be available from the Trained officer supplying pharmacy in a secure environment? And witnesses Many hospital pharmacies are not geared up to Pharmacist routinely print these. ecure environments Current service user Need to have a system where the prescriber writes onto a chart rather than writes prescriptions so this needs to be part of the review process David Green Associate Director Community Health ervices East & outh East England pecialist Pharmacy ervices i NPA omitted and delayed medicines ii Managing patients medicines after discharge from hospital iii NMC tandards For Medicines Management iv reconciliation NICE East and outh East England pecialist Pharmacy ervices Transcribing Guidance Vs.1 Feb 25 th 2011 (DG) 8
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