Task | Completed | Notes/Comments |
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Resident Identification and Verification | | |
Confirm resident's identity using two identifiers (e.g., name and date of birth). | | |
Cross-reference identification with the resident's medical record. | | |
Medication Order Verification | | |
Review physician's medication order. | | |
Verify medication name, dosage, route, frequency, and administration time. | | |
Check for any allergies or contraindications. | | |
Medication Preparation | | |
Gather necessary supplies. | | |
Prepare medication according to the prescription and facility protocols. | | |
Label medication if required by facility policy. | | |
Administration Process | | |
Administer medication at the scheduled time. | | |
Verify the resident's willingness and ability to take medication. | | |
Administer medication using the correct route (e.g., oral, topical, injectable). | | |
Document administration details (e.g., date, time, dosage, route) on the resident's medication administration record (MAR). | | |
Monitoring and Observation | | |
Monitor resident for any adverse reactions or side effects. | | |
Assess vital signs if necessary. | | |
Document any observed reactions or changes in the resident's condition. | | |
Resident Education and Counseling | | |
Provide information to the resident and/or family regarding medication purpose, dosage, and potential side effects. | | |
Offer counseling on medication adherence and management. | | |
Documentation and Communication | | |
Record medication administration details accurately on the MAR. | | |
Communicate any concerns or changes in medication status to the healthcare team. | | |
Document any missed doses or medication refusals. | | |
Follow-Up and Quality Assurance | | |
Conduct regular audits to ensure compliance with medication administration protocols. | | |
Review incident reports and address any medication errors promptly. | | |
Implement corrective actions as needed to improve medication administration processes. | | |
Disposal of Medications | | |
Dispose of expired or unused medications according to facility policy and regulatory guidelines. | | |
Document medication disposal appropriately. | | |
Training and Competency Assessment | | |
Provide ongoing training and education to nursing staff on medication administration procedures. | | |
Conduct competency assessments to ensure staff proficiency in medication administration. | | |