Administration of Medications-Recording Medication Administration

Please review Chapter 5 with special attention to pages 130 - 135

Objectives

• Identify general guidelines to follow in recording medication administration.
• Describe the content of a resident's clinical record.
• Document accurately activities related to administration of medications and treatment.
• Describe the principles of clinical documentation.
• Demonstrate how to correct an error in a resident's clinical record.
• Describe how to document a medication that was not administered, held, or refused.
• Identify appropriate documentation procedures when medication is given at times other than when regularly scheduled.
• Demonstrate the process for correcting an error in documentation.
• Demonstrate the process for documenting a late entry in a clinical record.
• Discuss why it is important to follow federal/state laws/regulations and facility policy when documenting in a resident's record.
• Record resident's response to medication.
• Report medication errors immediately to the license nurse supervisor.

General guidelines

• Document clinical information according to facility policy.
• Prior to administering medication
• After administering medication
• Write clearly using ink. (black ink is usually required using military time)
• Initial or sign all documentation according to facility policy.

 The resident's clinical record

• A permanent record of care received and the resident's response to that care.
• A form of communication among members of the health care team.
• A legal document that can be subpoenaed by a court of law.
• Organization and forms used for documentation will vary between facilities.
• Examples:
• Documentation by exception
• Focus charting
• Computerized clinical records

The Medication Administration Record (MAR)
(Review page 119-120) You will see a picture of the MAR and step by step instructions on completing the record for each resident

• Clinical record of medications administered to a resident.
• MAR contains name of medication, dose, route of administration, and the time the medication was administered.
• Licensed nurses may choose to add additional nursing directions for administration on the MAR. Examples would be to crush medication or to take blood pressure before administration.

Progress or interdisciplinary notes - a narrative form of documenting symptoms, behavior, and other pertinent information.

• Progress notes could include a record of the resident's response to a medication, identification of possible side effects, and a record of the medication aide's oral or telephone reports to supervising licensed nurse. The medication aide should record the reasons a resident did not receive a medication. When a resident is given a PRN medication, the response to that medication should be documented.

Principles of documentation

• Record information in the correct resident's chart.
• Check the prescription label with the order recorded on the MAR.
• Follow facility policy for charting medications either before or after administration.
• Be specific-make sure all five rights get documented.
• Record only facts. Record only those things you observed, heard, or performed.
• Record events in the order that they occurred.
• Write D/C after the last dose of a med has been given, and cross out any remaining scheduled times according to facility policy.
• Do not skip lines or leave empty spaces on a page of interdisciplinary notes.
• If you make an error, do not erase it. Place ONE line through the error, and initial and date above the line, then continue writing the rest of your charting. NEVER erase or use white-out or obliterate by repeated marking over. Make sure the error is still readable after you correct it.
• Never use ditto marks.
• Always use correct terminology and facility approved abbreviations.
• It is recommended that a black pen be used to record in a resident's chart. Some facilities may have policies to record evening progress notes in green ink and night progress notes in red ink. Follow facility policy.
• Always print or write legibly. Identify charting with date, time and your name and title.
• Chart anything that seems important to you in regard to medications.
• Consult the supervising nurse and facility policy about charting procedures.
• All information recorded in a resident's clinical chart must be kept confidential. Access to clinical records is restricted by law. Follow facility policy.

 Specific situations

• Medication not given at scheduled time, refused by the resident, or "held".
• Circle the scheduled time on the MAR and initial.
• Record in the interdisciplinary notes or on the back of the MAR the reason the medication was not administered.

• PRN and STAT medications
• Chart on the MAR according to facility procedure.
• Record the reason the medication was administered including pertinent observations of the resident prior to and after administration of the medication in interdisciplinary notes.
• Always report pm and stat medication administered to the oncoming staff in the shift change report.

• Medication errors (review page 134)
• Wrong drug to resident.
• Wrong dose to resident.
• Wrong route to resident.
• Wrong time for medication.
• Reporting error to supervisor and physician immediately is crucial so that necessary remedial measures may be taken.
• Complete a medication error report form or incident report, according to facility policy.
• Review why the error occurred, and evaluate how you can avoid making the error again.