Medication Documentation Guidelines

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17 Questions

When must ALL medications be documented?

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

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

To establish a clear chain of custody of medications and ensure accountability

Who is responsible for filling out the Admission Medication List?

The nurse doing the resident intake

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

Write 'NKDA' or 'No Allergies'

What should be done with medications prior to storing them?

Document and count them

Where should medications be stored?

In a secure location, such as a refrigerator or cabinet/storage unit

What is the primary role of staff during medication observation?

To observe and notify a supervisor of any medication misuse

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

Notify a supervisor and document the incident

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

What is a best practice for documenting medication observation?

Documenting after the patient has finished taking the medication

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

To prevent pilferage and protect patient privacy

What is a key principle for observing medication administration?

Monitoring the patient closely and controlling the pace

What is the primary goal of Medication Management?

To oversee resident medications and ensure they are handled properly by staff and taken as prescribed

What is the role of staff in Medication Management?

To ensure medications are being handled properly and taken as prescribed by patients

What is NOT a primary responsibility of Medication Management?

Prescribing medications for residents

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

To record medications taken by residents

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

It regulates the observation of resident medications

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.

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