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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.
Documentation includes physicians order for date(s) of service when medication(s) were administered, to include the medication name, dosage, frequency, and method of administration.
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.
1:14 5:10 Medical record or in a permanent office log. The date the vaccine is administered. The vaccineMoreMedical record or in a permanent office log. The date the vaccine is administered. The vaccine manufacturer. And the lot number of the vaccine.
Proper documentation helps ensure patient safety. Document time, date, location, and type of medication injected.
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By law, the following information must be documented on the patients paper or electronic medical record (or on a permanent office log): The vaccine manufacturer. The lot number of the vaccine. The date the vaccine is administered.
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.
Ask your doctor, pharmacist or other vaccine provider for an immunization record form or download and use this form [4 pages]. Bring this record with you to health visits, and ask your vaccine provider to sign and date the form for each vaccine you receive.

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