ESSENTIAL INFORMATION ON A MEDICATION RECORD

All the information on the medication record must be legible and transcribed carefully to avoid errors. In addition to client information (name, date of birth, medical record number, allergies), the following information is necessary on all medication forms:

1. Dates. This information usually includes the date the order was written, the date the medication is to be started (if different from the order date), and when to discontinue it.

2. Medication Information. This includes the medication’s full name, the dosage, the route, and the frequency. Abbreviations used on the medication record should be standard abbreviations and follow the guidelines and restrictions of The Joint Commission, ISMP, and the health care institution.

3. Time of Administration. This will be based on the desired administration schedule stated on the order, such as t.i.d. The desired administration time is placed on the medication record and converted to time periods based on the institution’s time intervals for scheduled or routine medications. (Thus t.i.d. may mean 9 am, 1 pm, and 5 pm at one institution and 10 am, 2 pm, and 6 pm at another.) A nurse should always become familiar with the hours for medication administration designated by a specific institution. Medication times for p.r.n. and one-time dosages are recorded at the time they are administered. Abbreviations for time and frequency should adhere to The Joint Commission and ISMP guidelines.

4. Initials. Most medication records have a place for the initials of the person transcribing the medication to the MAR (Figure 12-1, A) and the person administering the medication (Figure 12-1, B). The initials are then written under the signature section to identify who gave the medication. Some forms may request the title as well as the signature of the nurse (Figure 12-1, C). The policy regarding initialing after each administration varies by institution and by charting system used.

5. Special Instructions (parameters). Any special instructions relating to a medication should be indicated on the medication record. For example, “Hold if blood pressure less than 100 systolic” or “p.r.n. for pain.”

In addition to the information listed above, some medication records may include legends, as well as an area for charting to indicate when a medication is omitted or a dosage is not given. See Figure 12-1, D, for a legend of omitted doses. Other medication records may have an area where the nurse can document the reason for omission of a medication directly on the medication record (Figure 12-1, E). Other information may include injection codes so the nurse may indicate the injection site for parenteral medications (Figure 12-1, F). In cases in which no injection codes are indicated, the nurse is still expected to indicate the injection site. Space may also be allotted for charting information such as pulse and blood pressure if this information is relevant to the medication.

DOCUMENTATION OF MEDICATIONS ADMINISTERED

MARs include an area for documenting medications administered. After administering the medication, the nurse or other qualified staff member must record his or her initials next to the time the drug was administered. For scheduled medications, a complete schedule is written out, and the initials are recorded next to each given time. As previously mentioned, this practice can vary by institution. With one-time dosages and p.r.n. medication, the time of administration is written and again initialed by the person administering it. The medication form has a place for the full name of each person administering medications, along with the identifying initials. This allows for immediate identification of the person’s initials if necessary. When medications are not administered, some records have notations, such as an asterisk (*), a circle, or a number corresponding to a legend on the MAR, to indicate this, or there may be an area on the back or at the bottom of the MAR for charting medications not given (see Figure 12-1, E). The type of notation used will depend on the institution. In addition to notations made on the MAR, most institutions require documentation in the proper section of the client’s chart. (Some institutions have a section designated “nurse’s notes.” At other institutions nurses may be charting on a progress note and indicate that notation “nurse’s notes”.

EXPLANATION OF MEDICATION ADMINISTRATION RECORDS

Many types of MARs are used, and these forms vary among institutions. However, despite the variety of forms, MARs contain essential information that is common to all and to their purpose. The MAR is used to determine what medications are ordered and the dosage, route, and time at which each is to be given. The MAR is also verified with the prescriber’s orders. Any MAR requiring transcription of orders should always be checked against the prescriber’s orders. In institutions where personnel other than the nurse transcribe orders, the nurse must double-check the transcription to make sure there are no discrepancies. Regardless of the variation in format for MARs, the information common to all is as follows:

A sample MAR is included in this chapter. As you look at the sample record, it is important to locate and identify the information common to all MARs, with focus on medications that are given on a continual basis.

USE OF COMPUTERS IN MEDICATION ADMINISTRATION

As in other businesses, the use of computers in health care facilities is increasing. As a result of the reported rise in medication errors, many health care facilities have instituted some form of computer-based medication administration. The literature supports the fact that one of the main causes of medication errors is the incorrect transcription of the original prescriber’s order. According to Michael Cohen in the book titled Medication Errors, (2007), “In transcribed orders, stray marks as well as marks intended as initials, letters, check marks, and so forth can also obscure or change the appearance of a medication order. Handwritten MARs can contribute to errors if they are crowded or illegible or present drug information in an inconsistent manner.” Typically, according to Cohen, “orders are transcribed onto the MAR exactly as written; the presentation of information may not be consistent, and error-prone abbreviations and dose expressions may be carried forth from the order.”

Many health care facilities have moved away from the written medication order and transcription of orders to the MAR to a computer prescriber order entry (CPOE). This system was designed to eliminate the problem of unclear and ambiguous orders, which was identified as a common reason for medication errors. Medication orders of the prescriber are either electronically transmitted or manually entered into the system. The CPOE system accepts orders in a standard format conforming to strict criteria. Once the order has been entered into the system, it is transmitted to the pharmacy to be processed. Depending on the institution and the sophistication of the software, information such as medication incompatibilities, medication allergies, range of dosages, and recommended medication times may be part of the system. This shows the importance of computers to the safe administration of medication. With the computer used to process medication orders, orders can be viewed on the computer screen or on a printout. A corresponding MAR is available at some institutions based on the computerized order entry. The computerized MAR allows the nurse to enter the charting of medications into the computer, as well as any other essential information relating to medication administration. Each institution generates its own medication record, following a specific format.

At some institutions after the entry of orders into the system, the computer automatically generates a list of all the medications to be given to clients on a unit and the times they are to be given. The computer has become an essential tool for medication administration at some institutions. It is important to note that the use of computers in reference to medication administration times varies from one institution to the next and the sophistication of the computer system depends on the facility and the software purchased.

MEDICATION DISTRIBUTION SYSTEMS

The medication distribution system varies from one institution to the next. The various distribution systems are discussed in the following sections.

Unit-Dose System

Many institutions use a system of medication administration referred to as unit dose. This system has decreased medication preparation time because the medications are prepared daily in the pharmacy and sent to the unit. Medications are dispensed by the pharmacy in individual dosages as prescribed. Packages provide a single dosage of medication. The package is labeled with generic and trade names (and sometimes manufacturer, lot number, and expiration date). Depending on the distribution system, the individual packages may be labeled with the client’s name and bar code. The medications are placed in a client-identified drawer in a large unit-dose cabinet at the nurse’s station. “The value of unit dose dispensing in preventing errors should not be underestimated. TJC standards require medications to be dispensed in the most ready-to-administer form possible to minimize opportunities for error” (Cohen, 2007). In Medication Errors (2007) Cohen points out that although unit-dose may be used, the system does not extend to all products. (Example: in many institutions nurses are responsible for reconstituting or preparing IV doses from floor stock drugs and no policy exists for double-checking accuracy of calculation, preparation, and labeling.) Errors therefore occur that a fully implemented unit-dose system could have prevented.

Unit dose is also used as part of another medication system in some institutions (e.g., a computerized unit dose medication cart). In the computerized unit-dose system, each dosage for the client is released individually and recorded automatically. This system is used for monitoring controlled substances and other items used in the unit (e.g., medications used by the unit in large volumes). The type of medication form used for this system varies from one institution to another. In some instances this system has decreased the amount of time spent transcribing orders or eliminated the need for transcription. In some institutions, however, transcription of medication orders to the MAR is still required. The prescriber’s orders are therefore written on a separate order sheet and sent to the pharmacy. Figure 12-2 illustrates the transcription of orders to the MAR.

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