CMS Manual System - Louisiana Department of Health and Hospitals

Identifying the essential information and how it will be obtained and
reported. It is important to consider who is responsible for obtaining the
information, which information should be collected, and how the information will
be documented. The information that is collected depends on therapeutic goals,
detection of potential or actual adverse consequences, and consideration of risk
factors, such as:
o Medication-medication, medication-food interactions;
o Clinical condition (for example renal disease);
o Properties of the medication;
o Black-box warnings; and
o History of adverse consequences related to a similar medication.
Determining the frequency of monitoring. The frequency and duration of
monitoring needed to identify therapeutic effectiveness and adverse consequences
will depend on factors such as clinical standards of practice, facility policies and
procedures, manufacturer‘s specifications, and the resident‘s clinical condition.
Monitoring involves three aspects:
o Periodic planned evaluation of progress toward the therapeutic goals;
o Continued vigilance for adverse consequences; and
o Evaluation of identified adverse consequences.
For example, when monitoring all psychopharmacological medications and
sedative/hypnotics, the facility should review the continued need for them, at least
quarterly (i.e., a 3 month period), and document the rationale for continuing the
medication, including evidence that the following had been evaluated:
The resident‘s target symptoms and the effect of the medication on the
severity, frequency, and other characteristics of the symptoms;
Any changes in the resident‘s function during the previous quarter (e.g., as
identified in the Minimum Data Set); and
Whether the resident experienced any medication-related adverse
consequences during the previous quarter.
An important aspect of the review would include whether the pharmacological
management of the resident‘s medical and/or psychiatric disorder is consistent