Does Your Team Need to Brush Up on Medication Administration Basics?

Proper training in medication documentation is crucial to providing consistent, high quality care. The medication administration record is an important part of the plan of care. Authorized persons administering medication must note every time they have given medication and document their own actions.

Ensure that your clinical teams are educated in clinical practice standards, including your state-specific regulations. Clinicians must follow them every time they administer medication. Their first-person account of medications they have given in the medical record communicates that the plan of care is being followed appropriately. It also provides a legal record should questions arise about a patient’s care.

Review the practices outlined here to be sure your team knows and follows them. If they need a refresher, you can find engaging courses that will reinforce their initial learning and make a difference in consistency of patient care. Such training can also help your organization avoid unnecessary risk that can come from lapses in clinical practice.

Why Accurate Documentation Is So Important

Documentation is a critical part of medication administration. It creates a record of events that describes the care provided and provides important information to others on the care team. It also serves as the legal document that confirms that a healthcare professional has performed medication administration.

The key to good documentation is to keep the information concise, complete, and factual.

Medication documentation is recorded on the medication record. It must be completed each time medications are provided. Typically, the medication record is printed on a form that provides a space for each day and time a medication is:

  • Scheduled to be taken.
  • Taken as a PRN (or “as needed”) medication.

The professional who is providing or assisting with medication administration must write their name or initials on the form at the time they give the medication. A staff member should never document in the medical record for another professional.

Clinicians should make it consistent practice to record their actions on the medication record each time they provide assistance. This means the information will be fresh in the clinician’s mind and help avoid errors in documentation.

The person administering or assisting with medication should avoid assisting another individual until documentation of the previous intervention is complete. In the event of a problem or adverse event, the documentation will serve as a vital link to other professionals in deciphering the facts. It must be correct and complete.

Finally, remember that if it isn’t documented, then it isn’t completed!

Make Documentation Clear and Concise

Accurate and timely documentation is the only efficient and effective way to communicate information in a busy environment. Documentation that is clear and concise can prevent errors and promote safety.

Documenting exactly what happened with details and specifics is important to those who will rely on the documentation to communicate individual issues, changes, or needs. Objective and accurate documentation is also the only way to fairly represent an employee’s interactions with individuals.

Personal opinions and interpretations of others’ words should not be in the medical record. They are not always a fair or accurate representation of another person’s intent. So, if an individual states, “I need a Percocet for my arthritis because it’s the only thing that helps,” the clinician should document exactly what they heard. They would document that the individual stated they need a Percocet for their arthritis, followed by quotation marks that contain the individual’s exact words, “it’s the only thing that helps.”

The chart is a legal document. A clinician will be held personally and professionally accountable for documented opinions, misinterpretations, and misrepresentations. Remember, opinions are not always an accurate reflection of the truth!

Accurately Represent Special Circumstances

Clinicians may encounter special circumstances in their professional setting that might affect the way they administer medications. Any communication concerning medications should be documented according to organizational policy.

If an individual is physically away from the care setting and does not receive assistance with their medication at the scheduled time, the clinician should record this on the medication record according to organizational policy. The staff member should communicate with the appropriate professional when any omission of medications occurs. Such a lapse could have serious and even severe consequences for the individual scheduled to receive the medication.

Your work setting may allow individuals to leave routinely to go to programs or activities, or occasionally to go out shopping or to lunch with family and friends. Regardless of the reason, it’s important that individuals continue to take and receive prescribed medications at the right times, if possible.

Managing Temporary Absences

It’s important to follow your organization’s policies for medication administration when individuals are away for a temporary absence. Managing this may include:

  • Transferring their medications to a pill organizer and giving it to the individual or a trusted friend or family member upon their departure.
  • Dispensing their medications into a sealed compartment, such as unit dose packaging, making it easier for the individual to take only those doses.
  • Giving the original container of medication to the individual or a family member upon their departure.
  • Adapting the medication schedule to match the times that the individual is consistently present. This alteration in scheduling must be prescribed by the individual’s physician or other authorized practitioner.

All of these interventions must be recorded on the individual’s medication record. If a healthcare provider changes a medication order and the staff member is permitted to record changes on the medication record, the original entry on the medication record should not be altered. Instead, the staff member should mark the original order as “discontinued,” then write the new order in a new space.

Important Reminders for Staff

Make sure your staff is aware of your organization’s policies and procedures for recording new orders and discontinuing previous orders. If a staff member is permitted to record a new or changed order on the medication record, they should record the exact information from the medication label. It’s good practice to have another authorized staff member check the entry for accuracy.

To review, ensure that clinicians are educated in the following practices:

  • Only document what you observe and do, not what another caregiver tells you occurred.
  • Document short, factual statements in the individual’s medical record concerning their condition or any events that you are aware of.
  • Never record opinions or personal comments.
  • Never go back into a medication record and record information under a previous date. This is referred to as “backdating” information and is an illegal practice. If you have new information to add, add the current date and time and indicate your newest entry by writing “Late Entry” beside it or according to organizational policy.

A Brief Word About Abbreviations

The use of abbreviations is convenient but does not come without risk. Abbreviations are commonly associated with errors that can potentially result in serious injury and even death. Shorter is not always sweeter, so to speak.

Because of this, the Institute of Safe Medication Practices, or ISMP, has created a list of abbreviations, symbols, and dose designations that should never be used. The Joint Commission also has a list of “do not use” abbreviations.

Your organization’s policies and procedures will identify which abbreviations are approved for use within your setting. Remember, when in doubt, clinicians should ask for clarification. It is always better to be safe rather than sorry.

A Refresher on Documentation Basics

Documentation that can withstand the scrutiny of peers, investigations, and legal inquiry must comply with all of the items and qualities that have been presented so far. In addition, the following must also be part of your clinicians’ written documentation:

  • Legible handwriting, including their signature
  • Black or blue ink
  • No blank spaces, which can imply that care was not given

The Rights of Medication Administration

One of a clinician’s professional responsibilities in assisting with medication is to learn the Five Rights of medication administration as they pertain to that task. It should be a natural part of their process.

Using the Five Rights is still a commonly known method, although some organizations have added as many as seven more. One of the most commonly added rights is the right documentation. To be sure that clinicians are addressing this, they should always follow your organization’s policies to determine the proper documentation procedure for all medications.

Following the Five Rights will help keep the persons your organization cares for safe and prevent medication errors. However, keep in mind that the rights are outcome goals, not simply a process. Your organization should have systems in place that help your team achieve these outcomes.

A clinician’s role in medication administration offers a unique opportunity to have considerable influence in a patient’s life. Be sure clinicians on your team are competent in following your procedures and documenting every intervention and interaction appropriately.

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Jennifer Burks

Lead SME Writer, Relias

Jennifer W. Burks, M.S.N., R.N., has over 25 years of clinical and teaching experience, and her areas of expertise are critical care and home health. She earned her Bachelor of Science in Nursing from The University of Virginia in 1993 and her Master of Science in Nursing from The University of North Carolina, Greensboro, in 1996. Her professional practice in education is guided by a philosophy borrowed from Florence Nightingale’s Notes on Nursing, “I do not pretend to teach her how, I ask her to teach herself, and for this purpose, I venture to give her some hints.”

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