Medication Management

The role of the outpatient RN in medication management for patients with chronic disease includes:

• Educating patients about medication purpose, proper use, possible side effects, and red flags
• Assessing patients for possible side effects and signs of medication misuse or non-compliance
• Reporting patient non-compliance and/or side effects to provider
• Refilling medications according to the clinic's approved protocol (details about this below)

Along with patient education and assessment, outpatient RNs in WA State may utilize protocols to refill medications for patients with chronic disease. There are restrictions on which type of medications can be refilled by an RN and protocols vary from clinic to clinic. When refilling medications, it is the RN's responsibility to review the patient's chart and lab-work, determine when the patient needs to come in for a follow up appointment, and recognize when a provider should be involved in the approval process.

A refill protocol is being developed for CarePoint. Once the protocol is in place, you will be asked to use it to independently refill medications for our patients, determine when patients need to come in for a follow up appointments, and assess the need to consult with a provider. Remember that until the protocol is approved, you must gain a provider order for each medication refilled.

1. Check the date that the medication was first prescribed and the date when it was last refilled.
   • Ensure that this medication (the same dose, route, and frequency) is on their current medication list.
   • Ensure that this medication is on the medication refill protocol list. If it is not on the protocol, you must obtain provider approval prior to refilling.
2. Check the date of the patient's last office visit and/or their last wellness exam.
3. Read the chart note from the patient's most recent visit.
   • Does the provider mention when they want to follow up with the patient? Is there any mention of the medication? Were there any provider concerns about the patient's medication use or lab-work?
   • If there are any signs of non-compliance (ie. the patient did not follow up appropriately or there are signs of medication misuse), consult the provider before refilling.
4. Review associated lab work (TSH, AST/ALT, Creatinine, etc.).
   • Are there any abnormal or missing lab values? If so, consult the provider before refilling.
5. Determine if you can safely refill the medication or if you need to consult with the provider first. Ensure that the medication is listed on the refill protocol and that the patient meets all criteria listed to safely refill.
   • If you do not refill the medication, call the patient to inform them and schedule an appointment. This will avoid inconvenience for the patient and the possibility of them running out of their medication.
   • When refilling a medication, double check the name, route, dose, and frequency on the order before submitting.
6. Document the above information and any actions taken in the patient's medical record.

The only medications that may be refilled independently by an RN are those listed on the medication refill protocol. This will likely include medications such as antihypertensives, thyroid medications, oral contraceptives, GERD agents, hyperlipidemia medications, allergy medications, and medicated creams and lotions.

The following are medications that may NOT be refilled without provider approval (see protocol for complete list):

• controlled substances (including opioids & benzodiazepines)
• antibiotics
• chemotherapy agents
• antipsychotics
• oral steroids
• NSAIDs (chronic use of NSAIDs must be approved by a provider)

Variation in Refill Protocols and Procedures in a Family Medicine Residency Network: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880654/

San Francisco Health Network - Standardized Procedures for Registered Nurses: https://www.sfdph.org/dph/hc/JCC/SFGH/Agendas/2019/August%2027/Creds__12%20SFHN%20RN%20Med%20Refill%20Protocol%20070819_Credentials.pdf

Medication Refill Standing Order: https://cepc.ucsf.edu/sites/cepc.ucsf.edu/files/Standing%20Order%20-%20Med%20Refill.pdf

Developing Standing Orders to Help Your Team Work to the Highest Level: https://www.aafp.org/fpm/2018/0500/p13.pdf

Piedmont Access to Health Services, Inc. - Standing Orders for Medication Refills by Non-provider Clinical Staff: http://splash.pathsinc.org/Policies/2011/09%20Clinical%20Protocols%20(Medical)/01-09-015%20%20Standing%20Orders%20on%20Med%20Refills%20(ov).pdf

Lake Superior Community Health Center - Medication Refills Protocol: http://files.midwestclinicians.org/sharedchcpolicies/Pharmacy/Medication%20Reconciliation%20and%20Refills/Medication%20Refill%200113.doc

Image: https://blog.cureatr.com/5-medication-management-services