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Clinical Nursing Skills

11.3 Documentation of Medication Administration

Clinical Nursing Skills11.3 Documentation of Medication Administration

Learning Objectives

By the end of this section, you will be able to:

  • Describe the nursing guidelines for documenting medication administration
  • Explain the importance of accuracy in documentation of medication administration
  • Demonstrate how to correctly document in a medication administration record (MAR)

Documentation of medication administration is part of the patient’s legal medical record. Not only does the documentation play a critical role in clinical decision-making, but it may also be used in situations when legal action might be initiated. For these reasons, it is critical that this documentation be accurate, complete, reliable, and timely. This section prepares you with the knowledge and skills to accurately document medication administration in the patient’s medical record.

Nursing Guidelines for Documentation of Medication Administration

After completion of administering medications, the nurse is responsible for documenting the medication administration as well as any required postadministration assessments. This step is the one in which the medication administration “rights” of right documentation and right response are verified. To ensure accurate documentation, guidelines have been developed to ensure that only approved abbreviations are used, documentation is timely, and there is adequate evaluation of the patient’s response to the medication.

Approved Abbreviations

When documenting medication administrations, it is important to use only approved abbreviations to avoid potential medication errors. Agencies should incorporate standardized abbreviations to ensure consistency and reduce confusion. Using data from the ISMP’s National Medication Errors Reporting Program, there are a number of error-prone abbreviations that have been linked to medication errors, which should be considered when creating standardized abbreviations. Although these abbreviations are suggestions for agencies to strongly consider avoiding, The Joint Commission’s published list of “Do Not Use” abbreviations that must be avoided should be incorporated into the organization’s “Do Not Use” list.

To avoid confusion, medication names should typically be spelled out in full. For example, abbreviations for hydrocortisone (HCT) and hydrochlorothiazide (HCTZ) may be mistaken. Likewise, oxytocin (OXY) may be mistaken for oxycodone or oxycontin. Although the decision of whether using abbreviations is allowed is at the discretion of individual agencies, certain abbreviations should never be used based on evidence-based standards and implemented regulations by accrediting agencies. For instance, the abbreviations for magnesium sulfate (MgSO4) and morphine sulfate (MSO4) must never be used due to the high risk of significant negative patient outcomes should an error occur. Medications that are enteric-coated may include EC to the right of the drug name, whereas extended-release medications may use ER or XR, and sustained release may use SR. You may also see antibiotics generally referred to as abx; however, documentation of the medication administration should list the antibiotic name in full.

When expressing dosages, it is best practice to avoid fractions and roman numerals. Fractions may be misinterpreted as a range, and roman numerals may be mistaken as a letter or the wrong number. For example, “1/2 tablet” may be mistaken as “1–2 tablets,” and “V” may be mistaken as the letter V or 10. Instead, using “half tablet” and “5” reduces the risk of confusion and error. Remember that trailing zeros should be avoided, and leading zeros should be used before a decimal point. For example, use 5 mg instead of 5.0 mg, as 5.0 mg may be mistaken for 50 mg. Likewise, use 0.25 mg instead of .25 mg, as .25 mg may be mistaken for 25 mg. Adequate space must be placed between the drug name, dose, and unit of measurement to avoid misinterpretation. For example, metoprolol 25 mg may be mistaken as metoprolol 125 mg without the necessary space between the medication name and dose, or it may be mistaken as 2500 g without the necessary space between the dosage amount and unit of measurement. Another best practice is to use commas when numbers are greater than one thousand. For example, use 100,000 units instead of 100000 units, which may incorrectly be transcribed as 1000000. Careful consideration should also be given to the measurement units. For example, use mL for milliliter instead of ml or cc; L for liter instead of l; units instead of IU, U, or u; and mcg for micrograms instead of µg. Drops may be expressed as gtt.

When expressing medication routes, writing out the route in full is the best way to avoid mistakes. However, some agencies may allow abbreviations for the route, such as right ear (AD), left ear (AS), each ear (AU), right eye (OD), left eye (OS), and each eye (OU). If agency policy allows other abbreviations for routes, these may include NAS (intranasal), PO (oral), SUBQ (subcutaneous), IM (intramuscular), IV (intravenous), IVP (intravenous push), and IVBP (intravenous piggyback). In addition, some medications, such as injections, require the administration site to be documented. For instance, right arm (RA), left arm (LA), right leg (RL), left leg (LL), right lower extremity (RLE), left lower extremity (LLE), right lower quadrant (RLQ), left lower quadrant (LLQ), and abdomen (abd).

When expressing frequency, writing the frequency in full (i.e., daily, at bedtime, daily at 8 AM, 4 times daily) is safest. “Q” is often used to denote “every.” For example, daily may be written as QD or Q1d, but writing out “daily” is recommended. Similarly, orders may be written in terms of every so many minutes, hours, days (i.e., Q30 min, Q6h, Q2d). Nightly at bedtime may be abbreviated as HS or QHS; however, the ISMP recommends using just HS, nightly, or to spell out “at bedtime.” Medication frequency may also be expressed in relation to meals; for example, before meal (ac), after meals (pc), and before meals and at bedtime (achs).

Typically, symbols are not recommended when documenting medications. Instead of using > and <, best practice is to spell out the words more than and less than. Similarly, it is better to write out increase and decrease rather than to use directional arrows. Other symbols, such as @ and & may be mistaken as a 2 when handwritten, and + may be mistaken as a 4. Therefore, it is better to use the words at, and, plus, or in addition to. Weights should be stated as lb or kg instead of # to avoid confusion of whether the symbol is referring to a number or to pounds.

Timing of Documentation

Medications should be documented immediately after they are administered. Documenting at the time of administration reduces the potential for error and helps to ensure the most accurate documentation. It also reduces the likelihood of duplicate administration and may alert the clinician to changes in the patient’s condition.

Medication administration should not be documented prior to the administration, as the patient’s current condition may impact the ability to administer the medication. For example, the nurse may document the IV medication before administration, only to find the IV had infiltrated upon entering the patient’s room. Other examples may include documenting oral medications before administration, only to find the patient cannot safely swallow, or documenting that a medication was given, only for the patient to refuse the medication when it is administered. Not only may the patient’s condition change, but there is also a risk of the nurse documenting the administration of the medication and then forgetting to administer the medication.

Evaluation of Medication

After administering medications, it is important for the nurse to ensure the medication had the intended outcome, as part of the nursing process. For instance, did the patient’s blood pressure decrease after administering blood pressure medication? Did the patient’s fever decrease after administering a fever reducer? If the medication did not result in the intended outcome, it is important for the nurse to report the patient’s response, or lack thereof, to the provider, as well as document the response in the patient’s chart.

The timing of this evaluation depends on the onset of the medication. Typically, oral medications should be evaluated within 30 minutes to one hour after administration, whereas IV medications should be assessed much sooner. Depending on the medication administered via the IV route, evaluation can occur from five minutes to 15 minutes after administration. Although these are guidelines, the nurse should follow the agency’s policies regarding time frame for evaluation of medications.

In addition to the intended response, the nurse should document any noted adverse reaction following the administration, including any allergic responses. For example, the nurse may note a rash on the patient’s body 30 minutes after administering a new medication. The nurse should document the patient’s reaction to the medication within the medication administration record (MAR) and write a progress note detailing the patient’s response to the medication. The progress note should also include a statement that the provider was notified and any additional orders that may have been received.

Medications administered on a PRN basis must also be evaluated. When administering the medication, the indication for the PRN medication must be clearly identified. For example, if Benadryl is administered PRN itching, the nurse must document the assessment findings related to the itching. If the medication is being administered for pain, then a pain assessment must be performed and documented. The nurse must also reassess the PRN indication according to the medication’s onset, documenting the patient’s response. For example, if an oral pain medication is administered, the nurse may reassess the pain about 30 minutes to one hour after administering pain medications, whereas the patient’s pain should be assessed within 10–15 minutes after administering an IV pain medication.

Accuracy of Documentation

Thorough and accurate documentation is critical for clinical decision-making and the delivery of high-quality care. The patient’s medical record serves as a communication tool for the interdisciplinary team and is crucial for ensuring continuity of care. Not only does accurate documentation inform the care team of the patient’s current situation and allow for treatment decisions to be made, but it also provides legal evidence that may be used in the court of law. Therefore, accurate documentation is needed to provide the very best care and to mitigate risks.

Patient Refusal of Medication

Patients have rights, including the right to refuse medications. Should the patient refuse a medication, the first step is to determine why the patient is refusing the medication. Once the reason for refusing the medication has been determined, the nurse can then plan how best to proceed. For example, the nurse may determine the patient is refusing the medication because at home they typically take the medication at night instead of in the morning. The nurse may then collaborate with the pharmacy to reschedule the dose for nighttime. Or perhaps the patient experiences difficulty swallowing. The patient may refuse to take the medications whole but is amenable to taking the medications crushed in applesauce.

Within this assessment, the nurse should also understand why the medication is necessary. There may be times when patients lack the capacity to make sound decisions. It is important to consider if the patient has the capacity to fully understand the implications and make an informed decision to refuse the medication. For example, some mental health conditions such as dementia, conditions that cause a lack of consciousness, and intoxication may prohibit the patient from being fully aware of the implications of their decisions. Another instance may be children refusing medication out of fear without being able to fully make an informed decision. Although the child may not want to take the medication, the decisional capacity lies within the caregiver to provide consent.

It is important to listen to the patient, identify their concerns, ask questions to better understand the patient’s perspective, and provide clarity to ensure the patient is appropriately informed. The nurse may express a different viewpoint of the situation; however, the nurse should avoid arguing with the patient or minimizing the patient’s concerns. It may also be helpful to provide the patient with options, when possible, to allow the patient more control over the situation. For example, the patient may refuse a suppository but be amenable to taking an oral form of the medication. Another strategy may be to include the patient’s family or caregiver. For example, the patient may refuse medications administered by the nurse but will take the medications if administered by a trusted family member.

There may also be times where an alternative is not possible. In these cases, it is crucial to educate the patient. This education may include why the medication was prescribed, the benefits, as well as potential health outcomes if the medication is not administered. By educating the patient, the patient may make an informed decision to refuse the medication. Another strategy may be to give the patient time to consider the decision and then follow up with the patient a few minutes later to see if they have reconsidered taking the medication.

Patient Conversations

What If Your Patient Refuses a Medication?

Nurse: Mr. Blackwell, I see your breakfast arrived, so I went ahead and brought your insulin.

Patient: I’m not taking insulin.

Nurse: Can you tell me a little bit about why you don’t want to take it?

Patient: I don’t take insulin at home. I take metformin at home, which I’ve already had today.

Nurse: I do see the metformin listed here on your home medication list; however, your provider would also like for you to take insulin while you are here in the hospital. Factors such as stress, surgery, and antibiotics are known to increase blood sugar levels. Therefore, the insulin is used in combination with your metformin to better control your blood sugar since you just had surgery and are on antibiotics.

Patient: I know what increases blood sugar levels; however, I’m still not taking insulin.

Nurse: Mr. Blackwell, can you tell me what your blood sugar typically runs at home?

Patient: About 114.

Nurse: This morning, your blood sugar is 152. It likely increased due to having surgery yesterday, the antibiotics, and overall stress on your body. The insulin will help to bring your blood sugar down to your normal range. We use a sliding scale, so we can tailor the insulin dosage according to your blood sugar level.

Patient: Maybe so, but I’m still not taking it.

Nurse: Mr. Blackwell, I understand you don’t take insulin at home, and you seem to understand that your blood sugar may be higher than usual. Can you help me to better understand why you don’t want to take insulin?

Patient: I’m afraid if start taking it now that the doctor will want to keep me on it when I go home.

Nurse: I appreciate your concern; however, the intent is not to send you home with insulin. It is intended to help control your blood sugar just while you are here in the hospital. When you go home, you will go home on your usual metformin.

Patient: I’m still not taking it.

Nurse: I will let your provider know of your concern with taking insulin. Given your blood sugar is higher than normal, you may consider limiting food and drink high in sugar and carbohydrates to provide the best control over your blood sugar. Do you know what carbohydrates are?

Patient: Yes, things like potatoes, crackers, pasta . . . all of my favorite foods.

Nurse: While they may be your favorite foods, avoiding them right now is necessary if you want to try to avoid insulin.

Patient: I understand and will certainly watch what I eat and drink. No soda or spaghetti for me.

If the patient refuses a medication, it is important to notify the provider and chart the refusal. This may include documenting the refusal in the MAR, as well as writing a nursing note in the chart that clearly states the patient’s capacity for decision-making, rationale for the refusal, education provided, and other actions taken by the nurse (including notifying the provider) (Figure 11.6). Any direct quotes provided by the patient should be included within the note; however, be cautious that the patient’s exact words are used if quotation marks are used.

A snapshot of a nursing note to document patient refusal of medication labeled with patient name and age, date of birth and room number, and medical record number. Patient name is Rose Sanchez, age is 40, date of birth is April 18, 1983, room number is 366M, and medical record number is 008222014. Following this information is a table detailing the date and time of the nursing notes, the details of the notes, and the electronic signature of the nurse.
Figure 11.6 Sample of nursing note to document patient refusal of medication. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Correcting an Error in Documentation

Errors in documentation should be corrected as soon as they are noticed, and the manner depends on whether the documentation is in electronic or paper format. If the medication is documented electronically, you can typically correct the error by clicking on the medication administration tab within the MAR and then proceed to edit the documentation. Although the electronic chart may be updated daily, most electronic medical records keep a log of all edits made. Although errors should be corrected when they occur, corrections should not be a common occurrence and may indicate too many distractions, or the nurse may need to pay closer attention to the task at hand.

When documentation is handwritten on paper, mistaken entries may be noted by drawing a single line through the error, along with the date and your initials. It is important to use only one line to strike through the error. Do not use multiple lines, squiggly lines, Wite-Out, or attempt to erase the error.

Medication Administration Record

The medication administration record (MAR) is used to document medication administration. The MAR is a comprehensive record that tracks the medications that have been administered, the dose, the route, the time administered, any instructions that were provided, who administered the medication, and who ordered the medication. It should also list the indication for PRN medications, the effectiveness of PRN medication, and any medication reactions noted.

The electronic medication administration record (eMAR) is electronically populated according to the provider’s orders and often automatically populates much of the necessary documentation, such as the drug, route, PRN indication, provider’s name, and name of the person administering the medication (based on the log-on information provided). Typically, the time is defaulted to real time (as medications should be administered in real time); however, the nurse may alter the time, if needed. The eMAR provides additional layers of safety, such as displaying administration instructions, prompts when additional assessments are required, and pop-up alerts to notify the nurse of potential problems, such as contraindications, allergies, the administration being too close to another administration, or that the medication has been discontinued (Figure 11.7). Although the eMAR is convenient and offers a multitude of safety features, it is important for the nurse to use their own clinical judgment when documenting medication administrations and not become reliant on the eMAR.

A snapshot of an electronic medication administration record showing patient name, personal information, and details around medication given.
Figure 11.7 Example of documenting medication administration in the eMAR. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The nurse must also know how to document medication administrations via a paper MAR (Figure 11.8), as some agencies do not use eMARs, and those that do are subject to “downtime” in which the eMAR may not be available. When using a paper MAR, the medication order information, such as medication name, dose, route, frequency, prescriber name, and order date and time, must be accurately transcribed for each medication order, followed by the time in which the medication should be administered. Each MAR displays a particular time frame, typically for as much as one month, with the dates of the month typically indicated horizontally across the top of the MAR. Each agency may utilize their own MAR template; therefore, the location of each component may slightly vary.

A shapshot of a paper medication administration record detailing patient name and information as well as medication given and time administered.
Figure 11.8 Example of documenting medication administration in the MAR. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

To document a medication administration, the nurse would place their initials in the box associated with the date and time of administration. Subsequently, the MAR indicates a place for the nurse to record their initials, print their name, and add their signature, so that initials may be correctly identified should the need arise. If a medication is to be administered more than one time per day, it is best practice to leave a couple of lines between the scheduled time rows to prevent the initials from running together. If the medication dose is ordered as a range, the dose may be indicated in the box closest in proximity to the nurse’s initials. A line should be placed through any dates in which the medication should not be administered, for example, any dates that occurred prior to the medication order or after the medication was discontinued. Once the medication is discontinued, the nurse should ensure a line is placed through all subsequent dates, highlight the row yellow, and indicate if the medication order was changed or discontinued, along with providing the date and their initials.

In the event the dose is missed—perhaps the patient was not available during the scheduled time or the patient refused the medication—the nurse should place a circle around their initials in the box associated with the administration date and time, and then add a note to the back of the MAR to indicate why the medication was not given. Evaluation of the medication, including patient’s response to medication, PRN assessments, any other pertinent information should also be captured on the back of the MAR. Any follow-up assessments should also indicate the time frame in which the reassessment occurred.

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