What information is essential for the nurse to know when documenting a medication that has been administered?

Medication administration

Medication administration is a process that carries great responsibility in requiring that you know which medication is supposed to be given, as well as to whom, and when.  Remembering the various information that you need to keep track of can be overwhelming, but it is vital that you are aware of them.  We highly recommend familiarizing yourself with the seven rights of medication administration in order to protect both your patients and yourself.

Right Individual

Making sure that you have the right individual is obviously a very important step in medication administration.  The standard is to check with at least two other sources that you have the correct person before administering medication.  The most experienced of nurses can make a  mistake if tired, overworked, or managing several patients at once.  Despite your level of experience, you should always verify that you are giving the right person the right medication.

Right Medication

It goes without saying that ensuring that you have the right medication is paramount for a variety of reasons. Different patients can have different medical allergies, adverse reactions, and unexpected symptoms that could lead to catastrophic results.  Read the label of the medication, triple-check the patient’s charts, and make sure you are administering the correct medication for that patient.

Right Dose

The right dose is incredibly important as well, as the wrong dose could lead to overdosing a patient and possibly harming them.  The patient’s correct dose should be noted in their chart, and you should also know the form in which they should be receiving medication.  Are they taking pills, receiving medications through IV, or swallowing liquids?  These methods all require various doses. 

Right Time

Many medications have a specific time that they need to be administered, either due to the patient’s other medications or around their meals.  Not all medications require a specific time, but it is your responsibility to know which ones do and don’t.  Every time that medication is given to a patient, it should be recorded so that anyone treating them is aware of when medication was last administered. 

Right Route

“Route” in this case refers to where and how the medication is given to a patient.  While most medications are taken orally, this is not always the case.  The notes surrounding the way that medications should be administered are important to keep communication clear as nurse shifts change or others administer medication.  Medication can be given in several ways including rectally, vaginally, through the skin, in the eyes, in the ears, into the lungs, etc.  This leaves a lot of room for error if not correctly communicated. 

Right Documentation

It is the sole responsibility of the person administering the medication to properly document that administration.  Without proper documentation, communication can get lost between medical professionals.  Always double-check your documentation and make sure that all details are present and correct.

Right Response

Last, but certainly not least, is the response that the patient has to the medication administered.  Anytime that a patient is given medication, their response should be recorded to make sure that it is known to all treating the patient.  Additionally, the level to which the medication helps the patient should be recorded to keep track of what medication is working and what isn’t.  

4.4. Documenting on the Medication Administration Record (MAR)

1.  Discontinued meds: Write the date and DC large then draw a line through the rest of the dates and indicate discontinued; use a transparent yellow marker to highlight the name of the discontinued medication.
2.  New meds: transcribe new medications at the bottom of the list; draw a line through dated boxes up to the start date.
3.  To create a new MAR, copy from the physician orders. NEVER copy from the old MAR sheet.
4.  Each medication must be documented at the time of administration. For example, if eight medications are administered the QMAP must initial the MAR eight times indicating that each medication has been administered, refused or unavailable.
5.  New order: transcribe new medications on the MAR. A good practice is to keep routine and prn medications on the MAR.
6.  Follow your facility policies and procedures re notification of new medications.

What to do if:

1.  You make a charting documentation error: Draw a single line through the mistaken entry and initial and date. Explain on the back of the MAR.
2.  Medication cannot be administered because it is not available or is refused: Circle the date box with your initials, document the exact reason on the reverse side (or other designated area) of the MAR and contact the appropriate person according to facility policy.
3.  Give the client the wrong dose of medications: report to supervisor and follow facility policies and procedures.
4.  Late entry documentation: Circle the date box with your initials and you MUST document in the notes section of the MAR.

        Medication Administration Records should be developed per agency-specific protocol. In some instances, pharmacies may generate medication administration records for facilities who administer an abundant amount of routine and/or PRN medications.

        Routine Medication Administration Record(contains ongoing medication orders; i.e. medicines are given on a daily basis. Also contains medication that is ordered on a one time only basis.) The following are examples of information to include on the MAR:

• Month and year that the Medication Administration Record represents.
• Date order was given, and date and time medication was administered.
• Initial of the person transcribing the order.
• Initial of the person giving the medication
• Name of medication, dosage, route, time,
• An area for staff signatures, initials or other means for agency-specific staff identification.
• Acronyms are used to describe the reasons why medications were not given. See agency-specific policy regarding approved acronyms.
• Sample acronyms describing reasons why medications were not given

            – R=refused

            – H=hospital

            – D=destroyed

• Client identification

• A most common method used for identifying residents before administering medications is photographs of residents in the medication administration records;
• Photos should be kept updated and photograph is to have the name of the resident on it

(Relying on other staff to identify residents for medication administration is not appropriate).

• Name;
• number (if applicable);
• date of birth;
• gender;
• height;
• weight.

• ALLERGIES (list in RED)
• Attending Practitioner
• Nutritional Information
• Other necessary medical information (i.e. seizure disorder, allergies, asthma, pregnancy);
• Other necessary behavioral information (i.e. checking, binging, purging, etc.).

• special diet;
• illness;
• food allergies;

Documentation for PRN medications is different.

        PRN (when necessary) Medication Administration Record(contains medications that have been ordered on an “as-needed basis”). PRN medications are given on an as-needed basis per the licensed practitioner’s order.

This record should contain the same information as the routine MAR. In addition, the PRN MAR should contain:

•       Documentation of time and amount administered;
•       Ongoing observation, inquiry, and documentation some two hours after administration will determine effective or ineffective results of the medication;
•       Documentation of the effectiveness of the medication;
•       There are two acronyms that need to be added to the record to describe this (i.e. I=ineffective; E=effective).

Some Agencies May Have an Over The Counter Medication Administration Record.

ALL medications should have a “practitioner’s order”. Over the counter medications do not require prescriptions for purchase, but should be included on the practitioner’s standing medication order.

This record should contain the same information as on the PRN Medication Administration Record. In addition, there should be:

•   Documentation of “why” the medication was given (i.e. complaints of headache).

1.  Initial appropriate box. Document on the reverse side (or other designated area) on the MAR the time, dose, and reason why PRN medication was administered.
2.  Check back with the client within 30-60 min and document the client’s status (better or worse?) on the reverse side (or other designated area) on the MAR. Contact the appropriate person if necessary, a document that you have notified the supervisor if a client is not improved.
3.  Psychotropic meds cannot be given PRN except in residential treatment facilities for the mentally ill or if the client understands the purpose of medication and is capable of requesting it.

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