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Helping Your Family Member Adjust to Nursing Home Living-Tip #34

To ensure accurate and proper “med pass,” the nurse must adhere to the Ten Rights of Medication Administration. The eighth right, the right documentation requires a precise nurse to record every medication administered, including any related facts. The nurse should sign and/or initial the Medication Administration Records (MAR), immediately after the meds are given. If a nurse fails to document that a med was given, another nurse may accidentally administer a second dose of the same medication (unaware that a dose had previously been given). High alert medications may require a second signature. The nurse must also document if a medication was not given, including the reason. This is frequently done by the nurse initialing the appropriate area and then, circling their initials. Specific and relevant information is also documented on the MAR, for example blood pressure, pulse rate, blood sugar level, location of a medicated patch/injection site, amount of insulin given and pain level. The resident’s assessment, response to medication and teaching are equally important to document in the records. The medical records are legal documents required by regulation and law. These records are a means of communication to the other health care providers. These steps must be followed to ensure that safe administration is accompanied by the right documentation. This is basic training, usually taught to nursing students before they ever actually pass medication to residents. If there is any doubt about a medication that a nurse gives to your loved one, ask the nurse to confirm if it is the correct medication and/or if it was actually ordered.