Psychotropic Audit Documentation

V 2.0

Introduction

Resident Selection

Residents Included

All residents who had an active order for a psychotropic medication.  Psychotropic medications are indicated by their GPI class, regardless of other possible uses.

Business Rules

Tasks:

  1. Order Diagnosis - MD order for Psychotropics includes a diagnosis or indication (Q1201)

    1. Location in PCC:

      1. Orders

    2. Business Rule:

      1. IF a resident has an order for psychotropics
        THEN the order must include a diagnosis or indication

    3. Due Date:

      1. Within 24 Hours of the order date

    4. Is classified as missed on the report:

      1. N/A

    5. Is no longer relevant to the report:

  2. If the psychotropic medication order is no longer active. 

  1. Psychotropic Medication Administrated MAR - Psychotropic medication is documented in the MAR without charting omission. (Q1209)

    1. Location in PCC:

      1. Orders

      2. MAR

    2. Business Rule:

      1. IF a resident has an active order for psychotropic medication,
        THEN the administration must be filled out correctly in the MAR

    3. Due Date:

      1. The scheduled time of administration

    4. Is classified as missed on the report:

      1. The next scheduled time of administration

    5. Is no longer relevant to the report:

      1. If the order is no longer active

  2. Antipsychotic PRN Schedule - Antipsychotic medication orders on a PRN schedule are valid for no longer than 14 days (Q1204)

    1. Location in PCC:

      1. Orders

    2. Business Rule:

      1. IF a resident has an order for antipsychotic medication that is on a PRN schedule,

THEN the order must have an end date, and the end date should be no more than 14 days greater than the order date

  1. Due Date:

    1. Within 24 Hours of the order date

  2. Is classified as missed on the report:

    1. N/A

  3. Is no longer relevant to the report:

    1. If the psychotropic medication order is no longer active. 

  1. Side Effect Monitoring - Orders for side effect monitoring are in place (Q1210)

    1. Location in PCC:

      1. Orders

    2. Business Rule:

      1. IF a resident is has an active order for psychotropic medication

THEN the resident must have an active order for side effect monitoring that contains the words “side effect” and “monitor”

  1. Due Date:    

    1. Within 24 Hours of the order date

  2. Is classified as missed on the report:

    1. N/A

  3. Is no longer relevant to the report:

  1. If the psychotropic medication order is no longer active. 

  1. Behavior Monitoring - Orders for behavior monitoring are in place (Q1218)

    1. Location in PCC:

      1. Orders

    2. Business Rule:

      1. IF a resident is has an active order for psychotropic medication

THEN the resident must have an active order for behavior monitoring that contains the words “behavior” and “monitor”

  1. Due Date:

    1. Within 24 Hours of the order date

  2. Is classified as missed on the report:    

    1. N/A

  3. Is no longer relevant to the report:    

    1. If the psychotropic medication order is no longer active.