This document discusses medication administration and documentation. It defines medication and medication administration records. Safe medication administration is a major nurse responsibility. Nurses must follow the rights of medication administration which include the right patient, medication, dosage, route, time, documentation, education, refusal, assessment and evaluation. Proper preparation, administration at bedside while verifying patient details, and documentation are emphasized. Documentation must be complete and accurate in medical records. Electronic medication administration records are used to track medication administration and military time is used. Careful transcription to medical charts is important. Reasons for holding or refusing medication must be documented.

1. MEDICATION ADMINISTRATION
& DOCUMENTATION
Prepared By:
Ashly V Mani
Meeqat General Hospital ,Madina, KSA

2. DEFINITION
 Medicine may be defined as substance used to
promote health ,to prevent, to diagnose, to
alleviate or cure diseases.
 A Medication Administration Record (MAR, or
eMAR for electronic versions), commonly
referred as : it is the report that serves as a
legal record of the drugs administered to a
patient at a facility by a health care
professional.

3. The safe and accurate administration of
medication is one of the major responsibility
of nurse.
Medication will be administered by register
nurse who complete the medication
administration competency successfully.
Administration of medications
Key points

4.  Right patient
 Right Medication
 Right Dosage
 Right route
 Right time
 Right documentation
 Right client education
 Right to Refuse
 Right Assessment
 Right Evaluation
RIGHTS OF MEDICATION
ADMINISTRATION

5. Preparing To Administer A
Drug
 Give only drugs that the doctor is orders(use
drug reference if necessary).
Medications must be prepared for one patient at
a time .
*Prepare in a well-lit area
*focus on task, avoid distractions
Calculate the dose carefully
Do not leave a prepared drug unattended.-never
give a drug that someone else prepared.

6.  At the patient's bedside, verify the patient's name and
medical record number on the Medication Sheet and
the ID band. Advise the patient if appropriate, the
patient's family about potential clinical adverse
reactions, or other concerns when administering a
new medication.
 Check for contraindications to patient receiving the
medication (i.e. allergies).
 The nurse shall remain with the patient until the
medicine is actually swallowed.
MEDICATION ADMINISTRATION

7.  The indication of the drug before administering.
 The Electronic medication sheet and Kardex is
up-to-date.
 For allergies and assess for reaction of drugs not
previously taken by the patient.
 Check label when obtaining medication from
storage.
 Do side by side comparison of the medication
with the written order and medication sheet.
Always check for

8.  A critical element of drug administration
is documentation.
 The standard is “if is not documented it
was not done.”
 The nurse should document that a drug
has been given after the client has
received the drug.
DOCUMENTATION OF DRUG
ADMINISTRATION

9.  The medication process requires clear
and transparent documentation in
patient records.
 Incomplete or incorrect medication
documentation may contribute to
inappropriate clinical decision-making
and adverse events.

10. The electronic Medication
Administration Record (MAR or
eMAR) is used to electronically
track and record administration .
Military time will be used to
document medication
administration
Be extra careful during
transcribing prescribed
medication to KARDEX

11. MEDICATION DOCUMENTATION IN
ALERT

14. Always Remember
 Any medications that is withheld
shall be document on eMAR as
HOLD and to sign the record.
 The nurse shall document in the
nurse's notes the reason the drug
not given and, if applicable, that the
physician was notified.
 If the medication is refused by the
patient it should be documented as
‘Cancel task’ and to be notify the
reason as refused.

18. SUMMARY
 Documentation is an important part
of safe medication administration.
 Sign medication sheet (eMAR)
immediately after administration of
the drug.
 Record only the medicine which you
have administered.
 Never record a medication before
it is giving to the patient.
 Record the effects observed.
 Record the medications that are
vomited by the patient ,refused by
the patient and those drugs that are
not administered to the patient and
the reason for not giving
medication.