Standardizing documention of schedule II prescription in a primary care clinic

Abstract

Standardization of processes and documentation in healthcare has continually been linked to quality of care. Implementation of new electronic health records (EHR), inadequate training, and lack of processes in place can all effect nursing documentation. The purpose of this project is to standardize documentation of charting the destruction of schedule II prescriptions in an Internal Medicine Clinic. Prior to the implementation of this project there was no standardized workflow for how or where to document the destruction of schedule II prescriptions. Lack of standardization and protocol contributed to prolonged time to complete refills, increased risk of duplicates, increased risk of harm to patients, and high nurse utilization. A pre and post-test was utilized to evaluate the nurse practice on documenting the destruction of controlled prescriptions. The pre-intervention results demonstrated inconsistent documentation which included: documenting in a communication encounter, documenting in the medication tab, a mixture of both documenting in the communication encounter and medication tab, or just not documenting. A standardized workflow was developed, presented to nursing staff, and competency assessment completed. The post-test demonstrated 100% compliance in documentation and made locating the documentation in the chart faster and easier reducing nurse workload.