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    23.6 Medication Documentation

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    Lau Ren
    The nursing policy requires nurses to document all administered medications on the Medication Administration Record (MAR). This includes initialing the MAR after each dose, noting any required assessments like vital signs, and documenting any omitted or refused doses. Special documentation is required for insulin administration, including recording accu-check times and results, verifying insulin doses, and noting the site and amount administered. Newly prescribed medications also require documenting the patient's response.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    23.6 Medication Documentation

    Uploaded by

    Lau Ren
    10 views4 pages
    The nursing policy requires nurses to document all administered medications on the Medication Administration Record (MAR). This includes initialing the MAR after each dose, noting any required assessments like vital signs, and documenting any omitted or refused doses. Special documentation is required for insulin administration, including recording accu-check times and results, verifying insulin doses, and noting the site and amount administered. Newly prescribed medications also require documenting the patient's response.

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    Notes on medication documentation

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    The nursing policy requires nurses to document all administered medications on the Medication Administration Record (MAR). This includes initialing the MAR after each dose, noting any required assessments like vital signs, and documenting any omitted or refused doses. Special documentation is required for insulin administration, including recording accu-check times and results, verifying insulin doses, and noting the site and amount administered. Newly prescribed medications also require documenting the patient's response.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    10 views4 pages

    23.6 Medication Documentation

    Uploaded by

    Lau Ren
    The nursing policy requires nurses to document all administered medications on the Medication Administration Record (MAR). This includes initialing the MAR after each dose, noting any required assessments like vital signs, and documenting any omitted or refused doses. Special documentation is required for insulin administration, including recording accu-check times and results, verifying insulin doses, and noting the site and amount administered. Newly prescribed medications also require documenting the patient's response.

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    CONNECTICUT VALLEY HOSPITAL

    Nursing Policy and Procedure Manual

    SECTION F: MEDICATION POLICIES & PROCEDURES


    CHAPTER 23: MEDICATION MANAGEMENT

    POLICY & PROCEDURE 23.6: MEDICATION DOCUMENTATION

    Standard of Practice:
    The nurse will ensure that all medications he/she administers is documented on the Medication
    Administration Record (MAR).

    Standard of Care:
    The patient can expect that all doses of medication he/she receives from the nurse are
    documented in the patient’s medical record.

    Every medication given to a patient, including STAT and PRN orders, are charted on the
    Medication Administration Record (MAR). Charting is done as soon as possible after
    administration.

    Sign your initials, full name and title on each page of the MAR.

    When the medication is administered, the RN enters his/her initials opposite the appropriate
    medication and time, in the appropriate "date" column.

    Corollary Assessments required (i.e. vital signs, accu-check) for the administration of some
    medications are documented on the MAR. Apical pulse rate for patients on Digoxin is to be
    recorded on the MAR in the box below each signed-off dose. (See Example 1)

    EXAMPLE 1

    MEDICATION RECORD NAME OF PATIENT: M. Jones ALLERGIC TO: NKA

    MONTH
    YR December 20xx
    IDENTIFICATION
    NN Nancy Nurse, RN
    OF NURSES
    JD Jane Doe, RN
    (INITIALS AND
    SIGNATURES)

    Date Initials DRUGS * DOSE EXPIR HR 1 2 3 4 5 6 7 8 9 10 11 12


    Ordered MODE * INTERVAL DATE
    11/28/xx NN/JD Digoxin tab 0.25mg po qd 12/29/xx 8a NN
    Apical Pulse
    66

    23.6 Medication Documentation


    Revised 02/04, 05/05, 05/06,, 05/08, 11/09, 11/11, 04/12, 07/13
    Reviewed 07/15
    Page 1 of 4
    Use the lower portion of side 1 of the MAR for transcription of STAT and PRN Medications.

    STAT and PRN Medications: On the front of the MAR, record the time, including AM or PM,
    and your initials in the proper date column. Document the medication, reason given and the result
    on the back of the MAR. If another nurse assesses and documents the patients’ response to the
    medication from the nurse administering, he/she initials the result. For STAT medications, the
    STAT order on the MAR is discontinued once administered.

    Omitted/Refused Doses: Initial then circle the appropriate block on the MAR and write a
    corresponding note. Notes will be recorded on the back of the MAR. (See Example 2)

    Pain Assessment Documentation:


    1. On the front of the MAR, record the time, including AM or PM, and your initials in the
    proper date column. The nurse documents medication administered for pain, as well as
    the patient's response to the pain medication (efficacy) in the PRN Medication and
    Omitted Doses area of the MAR. The reason column denotes the specific patient
    complaint. The result column denotes whether the medication(s) had a positive effect or
    pain is relieved. If the medication does not provide relief, the RN will assess the patient’s
    pain, documenting the results in the Integrated Progress Notes. The ACS Clinician is
    contacted for further evaluation.

    EXAMPLE 2
    IDENTIFICATION NN Nancy Nurse, RN

    OF NURSES

    (INITIALS AND
    SIGNATURES)
    PRN MEDICATION AND OMITTED DOSES
    DATE HOUR INITIAL MEDICATION REASON RESULT
    11/27/xx 8am NN Motrin H/A #5 B-1
    11/29/xx 8am NN Digoxin Patient Refused -

    Medication education should be documented on the Patient/Family Education form and also in
    the Integrated Progress Note for medical conditions and the Psychiatric Progress Notes for
    related psychiatric conditions.

    Insulin Documentation:
    In a separate medication block record the time of accu-checks, including am/pm and results.

    The nurse who prepares and administers the insulin records his/her initials in the first hour
    block.

    The nurse who verifies that the correct type and dose of insulin was drawn, records the word
    “initials” in the second hour box, then records their initials in the corresponding day of the
    month.

    Record the word “site” in the third hour box. Record the site insulin administered in the next
    designated box. Site designations are as follows: Left Upper Extremity (LUE); Right Upper
    Extremity (RUE); Left Lower Extremity (LLE); Right Lower Extremity (RLE); Abdomen
    23.6 Medication Documentation
    Revised 02/04, 05/05, 05/06,, 05/08, 11/09, 11/11, 04/12, 07/13
    Reviewed 07/15
    Page 2 of 4
    (ABD) or Left Abdomen (LABD) and Right Abdomen (RABD).

    Record the word “unit(s)” (no abbreviations) in the fourth hour box when a sliding dosage
    of insulin is administered. Record only the number of units given in the adjacent box (i.e. 4)
    under the day of the month.

    Standing Coverage
    OriginalD Renewal DRUGS * DOSE * MODE * INTERVAL EXPIR HR 1 2 3 4 5 6 7 8
    ate Date DATE
    Ordered
    1/4/xx CO
    Lantus Insulin 40 Units daily at 9 p.m. 1/18/xx 9 p.m. CO JP BK MF CO
    LW SC x 2 weeks

    2nd LW LW LW LW LW
    Initials

    Site LABD RABD LLE RLE LUE

    Sliding Scale Coverage


    Do Accu-Chek every day at 6AM and 11AM for three days.
    Dr. Smith, MD
    OriginalD Renewal DRUGS * DOSE * MODE * INTERVAL EXPIR HR 1 2 3 4 5 6 7 8
    ate Date DATE
    Ordered
    1/4/xx CO
    Do Accu-check 6am JP JP BF
    LW Q6a – 11a – 4p
    X 3 days
    Results 230 210 220

    11am BF JP BF

    Site 190 185 190

    Give regular insulin SC to cover as follows:


    Below 180mg/dl. No insulin;
    180-200mg/dl, give 2Units;
    201-250mg/dl, give 4Units;
    251-300mg/dl, give 6Units.

    Original Renewal DRUGS * DOSE * MODE * INTERVAL EXPIR HR 1 2 3 4 5 6 7 8


    Date Date DATE
    Ordered
    1/4/xx JP 1/18/xx
    Do Accu-check 6a JP JP BF
    LM Q6A-11A-4p x 3 days
    With regular insulin coverage as follows 2nd
    Initials LM NS PD

    Below 180mg/dl, give no insulin


    180-200mg.dl give 2Units Site RUE RABD LUE
    201-250mg/dl give 4Units
    251-300mg/dl give 6Units

    Unit(s) 4 4 4

    23.6 Medication Documentation


    Revised 02/04, 05/05, 05/06,, 05/08, 11/09, 11/11, 04/12, 07/13
    Reviewed 07/15
    Page 3 of 4
    First Dose of Newly Prescribed Medications
    The nurse documents any change in the patient’s condition following administration of newly
    prescribed medication in the Psychiatric Progress Note section of the medical record and reports
    findings to the Physician. If there is a change in the physical health status following
    administration of newly prescribed medication, the Nurse documents this in the Integrated
    Progress Notes.

    23.6 Medication Documentation


    Revised 02/04, 05/05, 05/06,, 05/08, 11/09, 11/11, 04/12, 07/13
    Reviewed 07/15
    Page 4 of 4

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