Include the following evidence-based OASIS C/C1 best clinical practices for (M2020) Management of Oral Medications: the patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals.
Excludes injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness.)
- 0 - Able to independently take the correct oral medication (s) and proper dosage (s) at the correct times.
- 1 - Able to take medication (s) at the correct times if:
- (a) individual dosages are prepared in advance by another person; OR
- (b) another person develops a drug diary or chart.
- 2 - Able to take medication (s) at the correct times if given reminders by another person at the appropriate times
- 3 - Unable to take medication unless administered by another person.
- NA - No oral medications prescribed.
A Better Way to Ask the Question
What is the patient’s current ability - not willingness - to accurately take oral medications?
Instructions for Assessment
• Includes all prescribed and OTC (over-the-counter) medications that the patient is currently taking and are included on the plan of care.
• Exclude topical, injectable, and IV medications.
• Only medications whose route of administration is p.o. should be considered for this item. Medications given per gastrostomy (or other) tube are not administered p.o., but are administered "per tube."
• If the patient sets up her/his own "planner device" and is able to take the correct medication in the correct dosage at the correct time as a result of this, select Response 0.
• Select Response 1 if the patient is independent in oral medication administration if another person must prepare individual doses (e.g., place medications in a medi-planner or other device) and/or if another person in the home must modify the original medication container to enable patient access (e.g., removing childproof lids, marking labels for the visually impaired or illiterate), or if someone in the home must develop a drug diary or chart which the patient relies on to take medications appropriately.
• Select Response 2 if daily reminders to take medications are necessary, regardless of whether the patient is independent or needs assistance in preparing individual doses (e.g., set up a “planner device”) and/or developing a drug diary or chart. (Reminders provided by a device that the patient can independently manage are not considered “assistance” or “reminders.”)
• Select Response 3 if the patient does not have the physical or cognitive ability on the day of assessment to take all medications correctly (right medication, right dose, right time) as ordered and every time ordered, and it has not been established (and therefore the clinician cannot assume) that set up, diary, or reminders have already been successful. The clinician would need to return to assess if the interventions, such as reminders or a med planner, were adequate assistance for the patient to take all medications safely.
• If the patient’s ability to manage oral medications varies from medication to medication, consider the medication for which the most assistance is needed when selecting a response.
• If a medication is ordered prn, and on the day of assessment the patient needed a reminder for this prn medication, select Response 2. If the patient did not need any prn medications on the day of the assessment and therefore no reminders were necessary, assess the patient's ability on all of the medications taken on the day of assessment.