Chapter 12: MEDICATION ADMINISTRATION RECORDS AND MEDICATION DISTRIBUTION SYSTEMS Flashcards
MEDICATION ORDERS
- Before medications are administered, there MUST be an order with:
- Client’s name
- Name of medication
- Dosage
- Route, frequency, special instructions
- Signature of prescriber
- Computerized prescriber order entry (CPOE)
- Medication orders are transcribed to the Medication Administration Record (MAR)
MEDICATION ADMINISTRATION RECORDS
- Handwritten or electronic (eMAR) form used to document meds client has and will receive
- Method of charting varies per institution.
- MAR is also used to document patient refusals, delays in administration, and med responses.
Use MAR to:
Check the med order
Prepare the correct dosage
Record the medication administered
DOCUMENTATION: SIXTH “RIGHT”
SPECIAL CONSIDERATIONS to avoid errors:
* Transcribe carefully.
* Document immediately after medication administration.
* Document accurately.
* Document legibly.
* Document timely.
* MAR is a legal record.
* MAR is verified against orders daily.
ESSENTIAL COMPONENTS ON AN MAR
- Client information
- Name, DOB, medical record #, ALLERGIES
- Dates (when written, start and stop)
- Medication information
- Time of administration
- Initials (transcriber, person giving med)
- Special instructions
- Data such as BP, “Hold if …,” etc.
- Legends—describe abbreviations
DOCUMENTATION OF MEDS ADMINISTERED
- Complete schedule written or in computer
- Initialed or computer signed in appropriate area by med administrator IMMEDIATELY
after administration - One-time doses
- PRN doses (may be a different record)
- Refused or held meds (special symbols may correspond to legend)
EXPLANATION OF MAR
- MAR is always verified with the prescriber’s order.
- Despite variety in forms, contain the same essential information
- Name of the client and pertinent data related to the client
- Medication (dosage, route)
- Time/frequency desired for administration
- Allergies
- Date, administrator, initial and/or name
CASE STUDY:
You have new orders to discontinue the NGT and advance Mr. Ross’s diet from NPO status to clear liquids as tolerated. The physician writes the order:
Phenergan Supp 12.5 mg PR q4h prn nausea
After pharmacy transcribes the order, you compare the MAR with the order to verify. What components do you expect to see when reviewing the MAR?
answer:
* Mr. Ross’s full Name, DOB, medical record #, ALLERGIES
* Today’s date
* Medication information
* Time of administration
* Initials (transcriber, person giving med)
* Special instructions
* Legends—describe abbreviations
USE OF COMPUTERS
- Handwritten transcription and documentation are common causes of med errors.
- Goal is to eliminate errors and keep electronic records.
- Systems utilize CPOE and electronic MAR.
- Speaks to two QSEN competencies: safety to reduce risk of harm to clients, and the use of technology to mitigate errors
MEDICATION DISTRIBUTION SYSTEMS
- Unit dose
- Prepared daily and sent to unit
- Packages provide a single dosage of medication.
- Not available for all products
- Computer-controlled dispensing
- Automated dispensing system (ADS)
- Detailed transaction records
- Linked to pharmacy dispensing system
- Bar-code medication delivery
- Studies show errors reduced by 65%-86%.
- Verifies 5 rights:
- CLIENT, MED, DOSE, ROUTE, TIME
ADVANTAGES AND DISADVANTAGES OF TECHNOLOGY
- Advantages
- Improves accuracy and efficiency
- Safeguards the 6 rights (especially Bar- Code)
- Records can be readily accessed.
- Disadvantages
- Human component in USE of system
- Human component in RELYING solely on system
- Requires extensive up-front design and use planning
Abbrev: a. c
before meals
abbrev: p. c
after meals
What does CPOE stand for?
Computerized prescriber order entry
List three uses for the MAR
- check the med order
- prepare the correct dose
- record the medication administered
What types of systems are the Pyxis and Omnicel?
