Charting and Documentation
To ensure proper medication administration the health care worker must adhere to the six rights of medication administration:
- The right medication – comparison of the medication to the medication order is imperative. The administrator must only give medication they have prepared and be present when it is taken.
- The right dose – to ensure that the right dose is given, the administrator must triple check any calculations and have another team member check the calculation.
- The right client – the administrator must identify the client by checking the medication order and the client’s identification bracelet to ensure that the right client is receiving the right medication.
- The right route – the administrator must give the medication via the right route. In preparing the medication, the triple check will identify the route to be given on the medication order.
- The right time – the administrator will check the medication order to ensure that the medication is given at the right time. The prescriber will identify the times that the medication is to be given. (Abbreviations for medication times are on page two Standard Abbreviations )
- Proper documentation– the administrator will record the client’s status prior to the medication administration as well as the medication given, the time it was given, the dose given, and the route it was given in. Then the administrator will follow up and record the client’s response to the medication given.
Medication administration can be accomplished through the following routes: Enteral administration which consists of oral administration, through a NG Tube, rectal suppositories and enemas; Parenteral administration which consists of intradermal, subcutaneous, intramuscular and intravenous routes; and percutaneous administration which consists of topical medications, creams, lotions, ointments, transdermal drug delivery systems, topical powders and via the mucous membranes.
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Last Updated: 11/09/05