Documenting and reporting medications
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Documentation aims to preserve an accurate
record of patient assessment and interventions as well your reasons for giving
the care specified.
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Documenting a patients medications provide
a legal record of drugs he received during his stay in the health care
facility.
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Medication administration involves
documenting on a medication administration record as well as in the nurses
notes.
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Many hospitals also require the documentation
of opioid administration in a central record.
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After administering a drug, document the
following on a patient's Kardex or computer file: drug name, dosage, route and
time of administration, and your signature and title.
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In the nurses notes, include any
assessment data that refer to the patients response to the medication or any
adverse effects of the medication.
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If medication administered is to be
entered in a computer, ensure to enter each drug immediately after you give it.
This gives all health care team members access to current medication
information and is especially important if the system has no hard copy back up.
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If patient refuses or if unable to take
medication or if in your judgment, the patient shouldn't receive the
medication, document this on the medication administration record and on the
nurses notes.
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Many facilities use the Medication
administration record (MAR) to document the medication orders and
administration. Usually contained in the kardex file the MAR serves as the
central source for recording the practitioner's medication orders and documenting
the administration. It becomes part of the patient's permanent medical record.
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When using the MAR, know and follow the
hospital policy and procedure for recording medication orders and charting
medication administration. Make sure medication orders include the patients
full name, date ordered, drug dose, administration route or method, frequency
and time ordered for the first dose. Some drugs may be ordered with a specific
number of doses or a stop date. If that's so be sure to note this on the MAR.
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Always write legibly, use only acceptable
abbreviations, and use them correctly.
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When in doubt as to how to abbreviate a
term, spell it out.
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When documenting parenteral medications,
be sure to include the injection site and the route you used.
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After administering the first dose, sign
your full name, licensure status, and
identifying initials on the appropriate place on the MAR.
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If all medications have been given according
to the plan of care, no further documentation is needed. However if your
hospitals MAR doesn't include a place to document parenteral administration
sites , the patients response to p.r.n. medication or any deviation from the
medication order, further narrative documentation is necessary.
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Document any patient teaching given as
well as the patient's response and knowledge level.
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Report any untoward reaction of the drug
to the physician.
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Watch for the effect, adverse effects and
report appropriately.
COMMENTS