Medication Documentation Guidelines

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Questions and Answers

When must ALL medications be documented?

Upon arrival, when taken, if changed or discontinued, when returned to the resident, and when disposed (correct)

Only when administered by a nurse

Only when prescribed by a doctor

Only when the resident is discharged

What is the primary purpose of documenting all medications brought into the program by residents?

To monitor the resident's medication adherence

To ensure the resident's medication is not expired

To determine the cost of the medication

To establish a clear chain of custody of medications and ensure accountability (correct)

Who is responsible for filling out the Admission Medication List?

The resident's family member

The resident themselves

The nurse doing the resident intake (correct)

The program's pharmacist

What should be written in the 'Allergies' field if the resident has no allergies?

Write 'NKDA' or 'No Allergies' Signup and view all the answers

What should be done with medications prior to storing them?

Document and count them Signup and view all the answers

Where should medications be stored?

In a secure location, such as a refrigerator or cabinet/storage unit Signup and view all the answers

What is the primary role of staff during medication observation?

To observe and notify a supervisor of any medication misuse Signup and view all the answers

What should staff do if they suspect medication misuse during observation?

Notify a supervisor and document the incident Signup and view all the answers

Why is it important to inspect the medication cup before the patient ingests the medication?

Because once the medication is ingested, it cannot be recovered Signup and view all the answers

What is a best practice for documenting medication observation?

Documenting after the patient has finished taking the medication Signup and view all the answers

What is the purpose of medication check-in and storage?

To prevent pilferage and protect patient privacy Signup and view all the answers

What is a key principle for observing medication administration?

Monitoring the patient closely and controlling the pace Signup and view all the answers

What is the primary goal of Medication Management?

To oversee resident medications and ensure they are handled properly by staff and taken as prescribed Signup and view all the answers

What is the role of staff in Medication Management?

To ensure medications are being handled properly and taken as prescribed by patients Signup and view all the answers

What is NOT a primary responsibility of Medication Management?

Prescribing medications for residents Signup and view all the answers

What is the purpose of the Medication Observation Record (MOR) Sheets?

To record medications taken by residents Signup and view all the answers

What is the significance of the BSAS Regulation 105 CMR 164.406 (G) in Medication Management?

It regulates the observation of resident medications Signup and view all the answers

Study Notes

Medication Administration and Observation

Staff should observe residents as they take their medication to ensure adherence to prescribed directions.
Medication should be visually inspected before ingestion to prevent any errors or misuse.
Patient holds out the cup for staff to check the contents before taking the medication.

Documentation and Compliance

Document observations of medication intake accurately, including any potential misuse.
Recognize medication misuse as a symptom of Substance Use Disorder requiring therapeutic intervention.
Staff should prompt patients to take medications as prescribed, reading directions aloud if necessary.

Observation Best Practices

Maintain focus during observation; avoid distractions such as cell phones.
Do not document while residents are taking medication.
Administer one medication at a time and control the administration pace.

Medication Storage Procedures

New medications must be stored immediately to prevent theft and protect privacy.
All staff members are responsible for securely storing patient medications.

Medication Documentation Cycle

Medications must be documented throughout their lifecycle: upon arrival, when taken, if changed/discontinued, returned, or disposed of.
Documentation establishes accountability and clarity regarding medication custody.

Admission Medication List

Complete an Admission Medication List for all medications brought by residents, including prescriptions and over-the-counter products.
Include patient information, document allergies (if any), and note if no medications are present.

Training Content Overview

Topics covered in training include medication observation, storage, documentation practices, and maintaining refrigerator temperature logs.
Medication Management aims to ensure proper handling and administration of medications, fostering residents' skills for independent medication management post-program.

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Description

Test your knowledge of medication documentation rules! Learn when and how to document medications, including upon arrival, when taken, changed, or discontinued, and more. Ensure you're following proper protocols for storing and observing medications.