Charting Medications

Scheduled Medications

To chart an additional medication dose, complete these steps:

  1. Open a patient chart and go to Menu> MAR.

    scheduled med tasks
  2. In the Scheduled section, click the appropriate medication task (blue box) under the date/time column when medication was administered. The Medication window displays.
  3. The medication details populate automatically from the order.  Review the following information, making changes as needed:
  4. Some medications are associated with vitals taken at the time of administration.  If these fields are present, enter the information.

    MedicationWindow.JPG
  5. Sign IView_Sign.JPG the form and Refresh refresh button your screen.  The Medication Task shows the last dose given, as well as the vitals or other key details recorded at that time, if applicable.

    scheduled med complete

 

PRN Medications

Documenting PRN medications is similar to documenting scheduled medications, except that each administration of a PRN medication automatically creates a reassessment task.  The outcome of the PRN medication must be charted at a pre-defined interval (1 hour, 2 hours, etc. ) after giving the PRN medication.   

To document administration of a PRN medication:

  1. Open a patient chart and go to Menu> MAR.

    prn med task
  2. In the PRN section, click the appropriate medication task (green box) under the date/time column when medication was administered. The Medication window displays.
  3. The medication details populate automatically from the order.  Review the following information, making changes as needed:
    1. Dosage and route information
    2. Administration date/time
    3. Performed by
  4. Some medications are associated with vitals taken at the time of administration.  If these fields are present, enter the information.

    MedicationWindow_PRN.JPG
  5. Sign IView_Sign.JPG the form and Refresh refresh button your screen.  The Medication Task shows the last dose given, as well as the vitals or other key details recorded at that time, if applicable.  Additionally, a Medication Response task (blue box) appears on the MAR schedule.

    prn med given

 

To document medication response:

  1. Double-click the Medication Response task. A Medication Response Form displays.
  2. Record whether the medication was Effective.
  3. Document current Primary Pain Intensity, whether Vital Signs Improved and the Sedation Scale.
  4. Add detail to other sections as available / appropriate.

    medication response
  5. Sign IView_Sign.JPG the form and Refresh refresh button your screen.  The MAR will show the key response information, in this case, Primary Pain Intensity.

    prn response on mar