3.4.4: Documentation in the Medical Record

Pharmacology - Principles and Application for Medical Assistants · LibreTexts

0%

Contents

    Text

    Size
    100%
    Theme
    Typeface
    Line length
    Spacing

    From LibreTexts, under CC BY 4.0, as the source states it; its equations are written in TeX, which the PDF shows typeset. This page at LibreTexts.

    Any drug that the medical assistant administers must be documented in the patient’s medical record as soon as possible. Accurate and complete healthcare documentation is vital for high-quality, safe patient care. Documentation must include the patient’s name, date and time of administration, prescriber name, drug name, dose, route, technique, signature of the MA administering the drug, and any pertinent information gathered by the MA. Pertinent information may include patient pain level, vital signs, or patient response to a drug. Vaccine administration requires additional documentation, including the drug manufacturer name, lot number, and date of the CDC vaccine information statement issued to the patient (Hammer et al., 2019).

    Documentation examples:

    01/01/20xx 10:30am. Tylenol 1000mg tablet given by mouth to Veronica Guillen for headache as ordered by Dr Mansur. Patient states pain is at 5 on a 1–10 scale. Patient tolerated administration well, no adverse effects. Tomas Carvallo, CMA

    01/01/20xx 11:45am. Metoprolol 50mg tablet given by mouth to Shelby Saunders as ordered by Dr. Mansur. Patient heart rate 82 prior to administration. Patient tolerated administration well, no adverse effects. Aishah Bonner, RMA

    01/01/20xx 03:10pm. Depo-Provera 150mg administered to Christine Malley intramuscularly to left ventrogluteal muscle as ordered by Dr Mansur. UCG negative prior to administration. Patient has normal gait 30 minutes after injection. Laurie Stark, RMA

    01/01/20xx 11:20am Priorix prefilled syringe 0.5mL administered to Eliot Simon subcutaneously to right thigh. Manufacturer is GlaxoSmithKline. Lot number 1345689. VIS date 8/6/2021 provided to patient’s mother prior to administration. Patient tolerated administration well, no adverse effects. Hope Tucker, CMA

    This page titled 3.4.4: Documentation in the Medical Record was last modified on Fri, 30 Aug 2024 21:29:31 GMT and is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Anna Jannak (Consortium of Academic and Research Libraries in Illinois (CARLI)) .