That's a wrap!
Administration Records Review
Keep these important points about administration records in mind.
Drug administration record systems
Uses a form to record medication administration.
Computer charting
Medication administration information entered into a computer.
Automatic, computer-generated list of scheduled medications and their administration times.
Used increasingly over other systems.
Documenting drug administration
Write legibly in blue or black ink.
Record allergy information if it isn't already documented, using “NKA” if no allergies are known.
Transcribe from the doctor's order complete information about each drug (dates and drug names, dosages, strengths, dosage forms, administration routes, and administration times).
If parenteral, record the injection site.
Immediately document the times of all administrations.
If unscheduled, record the exact time the drug was given.
If given late or not at all, document the reason.
Always sign any documentation on the administration record.
Recording controlled-substance administration
Include date and time dose is removed from locked storage area.
Include amount of drug remaining in locked storage area.
Record the patient's full name.
Document the doctor's full name.
Enter the drug dose given.
Include your full signature (if a form is used; the nurse's password serves as a signature if a computer is used).
If any part of the drug was discarded, obtain the signature of another nurse who verified the amount discarded (or have her enter her password as verification if using a computer).