report of mdicines given to a patient

What information should be included in a medical report?

The details of the medical treatments given The regular medications The specification of the medicines given The side effects of the medications The patient’s past medical history The outcome of the illness or injuries The result from medications or treatments Other additional information relevant to the case

What would you do if you didn’t understand a medical report?

According to Johnson, the patients also said that if they didn’t understand the reports, they would take steps to have them translated into lay terms. Some said they would do their own research on the Internet; some said they would ask friends and family who were more knowledgeable about medical terms.

What is the importance of patient medical report?

Patient medical reportsserve as evidences that the patient has been given proper medications or treatments. Doctors or physicians are doing the best they could in order to supply the needs of each and every patient, regardless if they are in a critical condition or not. These reports are mandatory for the individual patient.

Should referring physicians give patients directly access to reports?

Yet another concern about giving patients direct access to reports is that it would cause referring physicians to lose some control in the patient-physician relationship. As with the other concerns, this one really hasn’t come true either.

What is a medication report?

A Medication Administration Record (MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional.

How do I report a medication reaction?

Use one of the methods below to submit voluntary adverse event reports to the FDA:Report Online.Consumer Reporting Form FDA 3500B. ... Call FDA at 1-800-FDA-1088 to report by telephone.Reporting Form FDA 3500 commonly used by health professionals.

Why is it important to record and report side effects of medication?

Rapid detection and recording of adverse drug reactions is of vital importance so that unrecognised hazards are identified promptly and appropriate regulatory action is taken to ensure that medicines are used safely.

Who can report ADR?

All healthcare professionals (clinicians, dentists, pharmacists, nurses) and patient/consumers can report ADRs to NCC or AMCs. The pharmaceutical companies can also send individual case safety reports for their product to NCC.

How do you write a adverse event report?

How to write an serious adverse event narrative?Patient details. ... Study details. ... Patient history (medical history, concomitant diseases, family history, and concomitant drugs) ... Details of the study drug. ... Event description and treatment details. ... Laboratory tests information. ... Action taken with the study drug. ... Outcome of event/s.More items...

What are IND safety reports?

IND application sponsors are required to notify FDA in a written safety report of: any adverse experience associated with the use of the drug that is both serious and unexpected or.

Why is it important to report medication errors?

Introduction: Medication errors have significant implications on patient safety. Error detection through an active management and effective reporting system discloses medication errors and encourages safe practices.

What to do if a patient is given the wrong medication?

I know this now from personal experience....There are several steps to appropriately dealing with a medical error that are relatively straightforward:Let the patient and family know. ... Notify the rest of the care team. ... Document the error and report it to the hospital safety committee.

Why is it important to report adverse effects of medication to the Medicines and Healthcare Products Regulatory Agency MHRA?

It is important that problems with medicines and medical devices and other nicotine e-cigarette products are reported, as the reports help identify new problems with these products. MHRA will review the product and if necessary and take action to minimise risk and maximise benefit to patients and the public.

When should ADR be reported?

Report if the patient was at substantial risk of dying at the time of the adverse reaction or it is suspected that the use or continued use of the product would result in the patient's death. Report if admission to the hospital or prolongation of a hospital stay results because of the suspected adverse reaction.

Where do you report ADR of drugs is passing from clinical trials?

You may report side effects to FDA at 1-800-FDA-1088.”6 Moreover, the recent focus on safety concerns surrounding several widely used products has intensified the focus on the drug safety system, and timely and complete ADE reporting continues to be an integral component of this.

Is adverse event reporting mandatory?

Reporting of adverse events from the point of care is voluntary. FDA receives some adverse event and medication error reports directly from health care professionals (such as physicians, pharmacists, nurses and others) and consumers (such as patients, family members, lawyers and others).

More people are taking prescribed medicines for longer

Some prescription medicines can be addictive and could cause problems for people taking them or coming off them, especially if someone has been tak...

Do not stop taking a prescribed medicine on your own

The medicines we looked at help to make millions of people every year feel better and recover from their illness. Doctors can prescribe them becaus...

What your doctor should do

Because of this report – and work being done by lots of others – doctors and other healthcare professionals should: consider all the treatments tha...

How to tell if a medicine is working?

Because of this report – and work being done by lots of others – doctors and other healthcare professionals should: 1 consider all the treatments that might work for you, including those that don’t involve (or are in addition to) medicines, like talking therapies or exercise 2 tell you about the benefits and risks of medicines 3 regularly review whether a medicine is helping you or not 4 change the treatment if it’s not helping you

Why can't you stop taking meds on your own?

Doctors can prescribe them because there is good evidence that they work, but they do have some risks. If you are a patient taking one of these medicines as prescribed by your doctor (or other prescriber), but you are worried by anything in this report, you should not stop taking them on your own.

Can PHE help with drugs?

PHE do not want to put anyone off safely using medicines that could help them. Stopping or limiting the use of medicines could also cause harm, including increasing the risk of suicide or making people try to get medicines or illegal alternatives from less safe sources, such as illegal websites or drug dealers.

Where to report controlled drug incidents?

Report incidents related to controlled drugs (including loss or theft) to your local NHS Controlled Drugs Accountable Officer (CDAO) at NHS England. You should also report incidents to the police (if necessary).

What are the consequences of medicine errors?

Medicine errors can result in severe harm, disability and death.

What is a near miss in NHS England?

NHS England defines a near miss as a ‘prevented patient safety incident’. A ‘near miss is an event not causing harm but has the potential to cause injury or ill health. Reviewing near misses can provide useful learning and areas for improvement.

What is NG67 in social care?

NICE guidance for adults receiving social care in the community (NG67) states: “When social care providers have responsibilities for medicines support, they should have robust processes for identifying, reporting, reviewing and learning from medicines-related problems.”.

What is the NHS's national reporting and learning system?

National reporting and learning. NHS England’s national reporting and learning system is known as NRLS. It states that 'low’ reporting from an organisation should not be taken as a ‘safe’ organisation. This may represent under-reporting. A ‘high’ reporting rate should not be taken as an ‘unsafe’ organisation.

What should be the primary concern in all cases?

In all cases, the safety of the person should be the primary concern. Where necessary, contact the prescriber or emergency services, the family or carer. Agree a process for care staff to follow. This should be agreed between health professional (s) and commissioners.

How to help someone with a medical emergency?

Act in an open and transparent way with relevant persons about the care and treatment provided. Tell them in person as soon as possible after finding out about the incident. Support them around the incident, including when you tell them what happened. Provide an accurate account of what happened.

What would happen if you didn't understand the medical reports?

According to Johnson, the patients also said that if they didn’t understand the reports, they would take steps to have them translated into lay terms. Some said they would do their own research on the Internet; some said they would ask friends and family who were more knowledgeable about medical terms.

Why do radiologists need to report patients?

By providing reports directly to patients, Berlin explains, radiologists can become more involved in their patients’ treatment decisions , as he believes they should. The days when doctors make unilateral decisions about patient care are long past, which is one reason for the change in reporting convention, he says.

Why are radiologists being sued?

But radiologists have been sued because patients weren’t told about the results of their diagnostic imaging exam, according to Berlin. “Unfortunately, there are instances where things like this can fall through the cracks,” he says. Providing patients with direct access to their reports can help eliminate this potential issue.

What is the piece of the puzzle that a radiology report is?

The radiology report is only one piece of the puzzle, and patients recognize that their doctors have the other pieces, such as medical history, symptoms, and physical exam. Their doctors are the ones who can put all the pieces together to reach a diagnosis and suggest treatment options, he says.

Why are radiologists opposed to providing their reports directly to patients?

One of the naysayers’ biggest concerns was that patients wouldn’t be able to understand the content of the reports and could easily misinterpret the results for the worst.

What was discussed at the 2012 RSNA?

A session at RSNA 2012 discussed how the practice is growing —and that radiologists’ concerns about providing reports directly to patients really haven’t come true.

Do radiologists have to send mammography reports?

About three years ago, a Pennsylvania state representative proposed a bill that would require radiologists to send reports of all exams directly to patients. The representative was the friend of a lawyer who was outraged when his wife wasn’t told of her cancer findings and died, Berlin says.

Who is notified of the disclosure of a patient's results?

The ordering physician is notified before the disclosure takes place and has access to the results as they will be conveyed to the patient/surrogate, if results are to be conveyed directly to the patient/surrogate by a third party.

What is the obligation of a physician to be considerate of patients?

Physicians have a corresponding obligation to be considerate of patient concerns and anxieties and ensure that patients receive test results within a reasonable time frame. When and how clinical test results are conveyed to patients can vary considerably in different practice environments and for different clinical tests.

How to ensure that test results are communicated appropriately to patients?

To ensure that test results are communicated appropriately to patients, physicians should adopt, or advocate for, policies and procedures to ensure that: The patient (or surrogate decision maker if the patient lacks decision-making capacity) is informed about when he or she can reasonably expect to learn the results of clinical tests ...

How are test results conveyed?

Test results are conveyed sensitively, in a way that is understandable to the patient/surrogate, and the patient/surrogate receives information needed to make well-considered decisions about medical treatment and give informed consent to future treatment.

Who is the first to see the results of a medical test?

In many cases, the physician receives the results and has assessed them for changes or abnormalities. However, at some medical facilities, medical assistants are the first to see the data, and can point out potential problem areas to the physician before he or she sees the patient.

What is the algorithm for breaking bad news to patients called?

There is an algorithm for how to break bad news to patients, even, called SPIKES. It’s best for the patient to hear both good and bad lab results from the physician, but if you as the medical assistant are tasked with this, it’s helpful to know how to handle it.

What is the diagnosis for upper respiratory infection?

Most times, the provider diagnoses the patient with an upper respiratory infection with no need for lab work or imaging. Other times, lab work is ordered, which means a Basic Metabolic Panel (BMP) or a Complete Blood Count (CBC).

Can you diagnose patients with a medical assistant?

This is extremely vital to remember. When becoming a medical assistant, one of the first things you’ll learn is that you should not diagnose patients or give them information on blood work, imaging studies, biopsy results, or anything of that sort unless told by a provider that it’s okay.

Do medical assistants give lab work?

Other times, the medical assistant will briefly educate the patient on their lab work, with permission from the provider. It’s important not to give information to the patient unless given the go-ahead from the physician. This is extremely vital to remember.

What happens after a report is reviewed by HPRA?

Once the report is reviewed by the HPRA, the reporter may be contacted for further follow up information that is considered to be significant to the evaluation of the suspected adverse reaction. Permission may also be requested to contact a healthcare professional directly for any further relevant information.

How to submit an adverse reaction report?

Certain mandatory fields are required to successfully submit an adverse reaction report via the online systems. These include reporter details and a contact email address. The latter facilitates return of a unique report identifier number, as a confirmation of a successfully submitted report. The confirmation email from the HPRA will also contain a PDF version of the report submitted. In addition, the following minimum criteria must be included for a ‘valid’ adverse reaction report: 1 An identifiable patient (i.e. patient initials/age/sex/record number) 2 An identifiable medicinal product (i.e. product name or active substance if brand is unavailable) 3 An identifiable reporter 4 An identifiable reaction

Why is it important to report adverse reactions?

The patients’ role in reporting adverse drug reactions is a key element in building an improved system of pharmacovigilance and the participation of patients is now at the core of the new medicines safety monitoring in Europe.

What does HPRA tell you?

They will tell you if you need any medical care. They will also consider if you need to change your treatment or if you need a different treatment. The HPRA has published an information leaflet for patients and other members of the public on side effects.

What is an adverse reaction?

An adverse reaction is formally defined as a ‘response to a medicinal product which is noxious and unintended’. This definition includes any harm associated with the use of a medicine including use following overdose, misuse or error.

Can you have a side effect from taking a medicine?

Most of us will not experience any problems when using medicines. However, all medicines have some risks associated with their use and so a small number of people may experience an adverse reaction (also known as a side effect).

Who can notify HPRA?

To your doctor, pharmacist or nurse who can then notify the HPRA.

How much of medication errors are prevented by nurses?

Nurses have always played a major role in preventing medication errors. Research has shown that nurses are responsible for intercepting between 50% and 80% of potential medication errors before they reach the patient in the prescription, transcription and dispensing stages of the process.

What happens when you make a medication error?

You immediately experience a physical and psychological stress response. Your blood pressure and pulse rate go up, your muscles tense and you are overcome by disbelief, panic, fear, anger and shame.

Why is medication error devastating?

Unintentionally harming of a patient through a medication error is devastating because it is in complete conflict with our nursing goal of caring and helping. Here are six things nurses need to know if they commit a medication error: 1. Medication errors happen all the time. Human error is a fact of life and mistakes with medication are ...

How many deaths are caused by medication errors?

Studies have shown that, besides increasing hospital stays and inpatient expenses, medication errors cause more than 7,000 deaths annually in the United States.

What happens if you don't report a mistake?

Should you not report the incident and the patient dies or suffers permanent disability from your mistake you will have to live with the guilt for the rest of your life. A cover-up may also be discovered and do more harm to your reputation, and possibly your career than that the mistake you made.

Which stage of the nursing process is most vulnerable to errors?

The administration stage is the most vulnerable to error because this is where there are fewer system checks and balances. In the hospital setting most medication is administered by a single nurse with the result that nurses’ errors are those most likely to reach the patient.

How to ensure that you are informed of your medical results?

Another way you can ensure that you remained informed of your medical test results is to make notes on your calendar of when medical test results should be released and communicated. If you have not heard from your doctor on that date, follow up and make sure that they are up to date on your treatment.

What happens if a doctor fails to disclose results of a medical exam?

If your doctor has failed to disclose the results of your medical exam, you may be entitled to legal relief. You should contact a personal injury lawyer as soon as possible while the events are still fresh in your recollection. An attorney can help specify your course of action if you have been injured as a result of your doctor’s errors.

Why do doctors not disclose test results?

A doctor might fail to disclose test results for several reasons. For one, they may simply forget to tell the patient about the test results. More often, test results can be lost or confused along the chain of communication in a hospital . Test results are often relayed between several different people, such as from a nurse to ...

Why is it important to keep medical records?

These records and receipts may be useful in reminding yourself and others what tests have been performed on you and what test results you are currently entitled to receiving.

What happens if you don't communicate with your doctor?

If your test results have been withheld from you, you may be entitled to legal relief. This could include monetary damages for any injuries resulting from the failure to communicate. You may also be able to obtain compensation for medical fees and other related costs stemming from the failure to communicate.

Do you have to know the results of a medical exam?

As the patient, you are entitled to know the results of your medical exams. All medical professionals are held to a high standard of medical care, and that standard of care includes informing the patient of the outcome of any medical test or examination, such as a colonoscopy or a mammogram, that is performed on them. Your doctor should also inform you of the purpose of the medical exam, and also of any dangers or side effects that might result from the exam.

Can you file a medical malpractice lawsuit?

Additionally , you may be able to file a medical malpractice lawsuit if your injury is particularly serious. You will have to prove in court that you received actual injuries as a result of the doctor’s failure to communicate test results. Also, you will need to prove that the failure to communicate test results is directly traceable to your doctor.