Q&A: Clarifying PC.02.03.01 EP4 (Medication education)
Q: The surveyor cited two behavioral health records not having documentation of medication education. Can I clarify this finding?
A: This is a little tricky, because documentation is not required to meet this standard. Therefore, determine if your hospital policy identifies how the nurse should educate patients on their medications in the normal course of care delivery. You may also want to consider the following:
- Have you reviewed your care plans and flow sheets for correlation to patient education and training?
- Are there records of competencies or in orientation that will support this education process?
- How did the surveyor determine this finding? Was it by speaking to the patient or just by examining the medical record?
- Were nurses or patients interviewed to determine that this didn’t occur?
An audit of records can show 90% compliance in this area.
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