Revisions Related to Medication Titration Orders

MM.04.01.01, EP 2 revisions

Effective January 1, 2021, The Joint Commission approved a revised EP for organizations that participate in the Ambulatory Health Care, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, and Nursing Care Centers accreditation programs to provide further clarity on the minimal components of a medication order. The revised EP, MM.04.01.01, EP 2 is also designed to improve the safety and quality of services for patients by giving further guidance for orders written for the administration of titrated medications for hospitals, critical access hospitals, and ambulatory health care organizations, home health organizations, and nursing care centers whose policies deem titration orders acceptable for use.

Clarifying note added to RC.02.01.01, EP 2

Effective September 13, 2020, The Joint Commission approved a revised EP for organizations that participate in the Ambulatory Health Care, Critical Access Hospital, and Hospital accreditation programs. Two notes were placed at Standard RC.02.01.01, EP 2 to clarify that block charting is an acceptable form of documentation in unique situations where frequent adjustments to one or more medications are necessary. Charting each individual rate change can potentially create undue burden when a patient requires frequent titrations of medication(s).

Prepublication Standards:

Prepublication Standards – Effective September 13, 2020 and January 1, 2021