· Documentation aims to preserve an accurate record of patient assessment and interventions as well your reasons for giving the care specified.
· Documenting a patients medications provide a legal record of drugs he received during his stay in the health care facility.
· Medication administration involves documenting on a medication administration record as well as in the nurses notes.
· Many hospitals also require the documentation of opioid administration in a central record.
· 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.
· In the nurses notes, include any assessment data that refer to the patients response to the medication or any adverse effects of the medication.
· 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.
· 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.
· 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.
· 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.
· Always write legibly, use only acceptable abbreviations, and use them correctly.
· When in doubt as to how to abbreviate a term, spell it out.
· When documenting parenteral medications, be sure to include the injection site and the route you used.
· After administering the first dose, sign your full name, licensure status, and identifying initials on the appropriate place on the MAR.
· 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.
· Document any patient teaching given as well as the patient’s response and knowledge level.
· Report any untoward reaction of the drug to the physician.
· Watch for the effect, adverse effects and report appropriately.