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CHAPTER 24MEDICATION ADMINISTRATION (CHARTING, DOCUMENTATION AND THE MED PASS)24.1NURSING Premedication Administration and Charting in the Nursing Home (UNDER QUALITY OF CARE REQUIREMENTS)I. Facility

How to fill out medication administration and charting

How to fill out medication administration and charting:

1. Start by gathering all the necessary information related to the medication. This includes the patient's name, date of birth, and any specific instructions or dosages provided by the prescribing healthcare professional.
2. Ensure that the medication being administered matches the medication order. Double-check the medication name, dosage, and any additional information, such as frequency or route of administration.
3. Record the date and time of medication administration accurately. This helps maintain a clear timeline of when the medication was given and allows for proper tracking and monitoring.
4. If applicable, document the patient's vital signs before administering the medication. This information helps evaluate the patient's response to the medication and ensures their safety.
5. When administering the medication, note the specific route used, such as oral, subcutaneous, intramuscular, or intravenous. This is crucial for tracking potential adverse effects or different absorption rates.
6. Record any changes or observations regarding the patient's condition before, during, or after medication administration. This may include any adverse reactions, side effects, or improvements observed in the patient.
7. Document any education or counseling provided to the patient regarding the medication. This ensures that the patient understands how to take the medication correctly and any potential precautions they need to be aware of.
8. Sign and date the medication administration record. This validates that the medication was administered by the appropriate healthcare professional and serves as a legal document for future reference.

Who needs medication administration and charting:

1. Nurses: Medication administration and charting are crucial responsibilities for nurses in various healthcare settings. They ensure accurate and timely administration of medications, track patient responses and potential adverse effects, and maintain a comprehensive record for effective patient care.
2. Physicians and Prescribing Healthcare Professionals: Proper medication administration and charting assist physicians and prescribing healthcare professionals in evaluating treatment effectiveness, adjusting dosages if necessary, and making informed decisions about patient care.
3. Pharmacists: Medication administration and charting help pharmacists coordinate with other healthcare professionals, ensure accurate dispensing of medications, and provide valuable input on potential drug interactions or adverse effects.
4. Healthcare Administrators: Accurate medication administration and charting records aid healthcare administrators in monitoring the quality of care provided, identifying patterns or trends in medication use, and ensuring compliance with regulatory standards.
5. Patients and their Families: Medication administration and charting allow patients and their families to have a clear record of the medications being taken, dosages, and any related instructions. This empowers them to actively participate in their own healthcare and have a better understanding of their treatment plan.

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