Documentation Checklist: Process Guidelines for Medication - michigan 2025

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At a minimum, documentation should include the date of service, the medication(s), and the risks and benefits specific to the patient. Documentation of prescription drug management is part of a higher level of service at moderate medical decision making. As such, proper documentation is key.
The Medication Administration Record (MAR) and Computerized Medication Administration Record (cMAR) serve as a legal record of the medications administered to a patient while in the care of the hospital and must be documented in black ink.
Right Documentation: Recording the Right Information in Medical Documents. Nurses must ensure that patients medication administration is accurately documented in the patients medical records. This includes documenting the medication name, dose, route, time of administration, and any adverse reactions or side effects.
The exact medication, dose, route, date, time, reason, initials of the person giving need to be documented when a PRN is given. Generally, 30-60 minutes after any PRN medication is given, the effectiveness of the medication needs to be documented per agency policy.
The times and dates the medication is to be taken 3. The initials of the person assisting with the medication 4. A start date should be noted; a stop date is noted when known 5. Identifying information about the individual, including date of birth, allergies, diagnoses, and names of medical providers.
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Nurses must ensure that patients medication administration is accurately documented in the patients medical records. This includes documenting the medication name, dose, route, time of administration, and any adverse reactions or side effects.
ing to the Centers for Medicare Medicaid Services, all orders for the administration of drugs and biologicals must contain the following information: Name of the patient. Age or date of birth. Date and time of the order. Drug name. Dose, frequency, and route. Name/Signature of the prescriber.

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