Effective 1 Jan 2021, Medication Management (MM) standard 04.01.01 element of performance (EP) 2 will include details for the requirements of a medication order, to include the required elements of a titrated medication order. Previously, the standard allowed a facility to define the required elements. The required elements of a medication order are now: 1) medication name, 2) medication dose, 3) medication route, and 4) medication frequency.
Titration required elements include: 1) the medication name, 2) medication route, 3) initial rate of infusion (dose/unit of time), 4) incremental units to which the rate or dose can be increased or decreased, 5) how often the rate or dose can be changed,6) the maximum rate or dose of infusion, and 7) the objective clinical measure to be used to guide changes (e.g. RASS score, etc).
In addition, for titration orders, a clarifying note has been added to Record of Care (RC) 02.01.01 EP 2 to allow block charting as an acceptable form of documentation in unique situations where frequent adjustments to one or more medications are necessary. This is allowed when a patient requires frequent titrations of medication(s) and charting each individual titration can cause undue documentation burdens. An example of the need for block documentation can be if an ICU patient is crashing or a patient that may be returning from surgery and titrations are changing immediately to stabilize the patient. A facility should have a clear policy on the time block documentation.