Documentation of patient information Overview of what is required Suggested approach Examples of evidence Audit of the use of adverse drug reaction alert report adverse drug reactions to the TGA (see providing education and training for the ). systems in electronic medicines management workforce on identifying, documenting and software. recording medication allergies and adverse drug reactions Orientation manuals, education resources and records of attendance at training by the guidance for the workforce on how to workforce about recording known medication communicate with consumers/carers when allergies and reporting adverse drug adverse drug reactions occur. reactions. Include information on known medication allergies and adverse drug reactions from service contractors, such as a community pharmacist, in the clinical record. consumer’s 4.7.2 Action is taken to reduce the risk of adverse reactions It is important that your community health service Use audits and quality improvement activities to Relevant documentation from committees and monitor adverse drug reaction documentation other meetings where reports on adverse drug monitors the quality and use of documented (see ). reactions are reviewed and quality improvement adverse drug reactions. strategies discussed. Use the results of audits to identify actions to improve documentation, reduce risks and guide Register of adverse drug reactions that includes actions to address identified risks and education needs, and ensure these are included in the relevant quality improvement plan (see ) documentation of completed actions. and risk register (see ). A quality improvement plan in line with that Consider using an adverse drug reaction includes actions to address issues identified summary sheet at the front of the and evaluation of outcomes. consumer’s clinical record, and allergy alert stickers on Examples of improvement activities that have paper-based records. been implemented to reduce the risk of adverse Where electronic clinical records are used, reactions, such as changes to policies, ensure that adverse drug reactions are procedures and/or protocols. recorded and visible when medicines are Orientation manuals, education resources and prescribed, dispensed, supplied and records of attendance at training of workforce administered. on: obtaining and documenting a medication allergy and adverse drug reaction history
Documentation of patient information Overview of what is required Suggested approach Examples of evidence report adverse drug reactions to the TGA (see ). providing education and training for the workforce on identifying, documenting and recording medication allergies and adverse drug reactions guidance for the workforce on how to communicate with consumers/carers when adverse drug reactions occur. Include information on known medication allergies and adverse drug reactions from service contractors, such as a community pharmacist, in the consumer’s clinical record. Audit of the use of adverse drug reaction alert systems in electronic medicines management software. Orientation manuals, education resources and records of attendance at training by the workforce about recording known medication allergies and reporting adverse drug reactions. 4.7.2 Action is taken to reduce the risk of adverse reactions It is important that your community health service monitors the quality and use of documented adverse drug reactions. Use audits and quality improvement activities to monitor adverse drug reaction documentation (see ). Use the results of audits to identify actions to improve documentation, reduce risks and guide education needs, and ensure these are included in the relevant quality improvement plan (see ) and risk register (see ). Consider using an adverse drug reaction summary sheet at the front of the consumer’s clinical record, and allergy alert stickers on paper-based records. Where electronic clinical records are used, ensure that adverse drug reactions are recorded and visible when medicines are prescribed, dispensed, supplied and administered. Relevant documentation from committees and other meetings where reports on adverse drug reactions are reviewed and quality improvement strategies discussed. Register of adverse drug reactions that includes actions to address identified risks and documentation of completed actions. A quality improvement plan in line with that includes actions to address issues identified and evaluation of outcomes. Examples of improvement activities that have been implemented to reduce the risk of adverse reactions, such as changes to policies, procedures and/or protocols. Orientation manuals, education resources and records of attendance at training of workforce on: obtaining and documenting a medication allergy and adverse drug reaction history
Guide-to-the-NSQHS-Standards-for-community-health-services-February-2016.docx