Recording Information
Accuracy checks of MAR's are done when?
1. Beginning of the month before the first medication administration.
2. Middle of the month after medications have already been administered.
3. End of the month to make sure that medication sheets were correct during the month.
1. Beginning of the month before the first medication administration.
This accuracy check must be done by two MAP certified Staff.
- Accuracy check 1
- Accuracy check 2
Both staff checks must include a full signature, the date, and the time completed.
What are the 5 Rights of Medication Administration?
1. Right Person
2. Right Dose
3. Right Time
4. Right Route
5. ?
5. Right Medication
If any of these 5 rights are not followed it is an MOR.
Depending on the error made it can cause something called a Hotline Medication Occurrence. A hotline event is when the individual requires medical attention due to one of the 5 rights not being followed and must be reported to DPH within 24hrs.
Which one of the following answers is NOT correct regarding the sections in a Countable Controlled Substance Book?
1. Index
2. Count sheets
3. Disposable count sheets
4. Count signature sheets
3. Disposable count sheets
There are 3 basic sections in a Countable Controlled Substance Book.
These books must be used when there is a countable controlled substance medication in the home.
There must be a shoulder-to-shoulder two person count at least once every 24 hours. The count must also be conducted every time the keys change hands to another MAP certified staff member.
A medication occurrence occurs when one of the 5 rights are not followed
True or False
True
Examples:
Wrong person
Wrong medication
Wrong dose
Wrong time/omission
Wrong route
What codes are not acceptable codes to use on a Medication sheet?
1. A- absent
2. LOA- Leave of Absence
3. V- vacation
4. MIA- Missing in Action
4. MIA- Missing in Action
Other Acceptable Codes:
1. A- absent
2. LOA- Leave of Absence
3. V- vacation
4. DP- Day Program/Day Hab
5. H- Hospital, nursing home, rehab center
6. NSS- no second staff
7. OSA- Off-site administration
8. P- Packaged (used only if the person is learning to self-administer their medication)
9. S- School
10. MNA - Med not administered
Only these acceptable codes can be used on the MAR.
When giving a PRN medication what is needed?
1. Your initials in the box at on the date it was give
2. The time above or below the box in which you initialed and gave the medication
3. ?
3. A progress note must be written on the back of the MAR stating:
a. The date
b. The time
c. The reason you gave the medication (It must be one of the reasons to give on the HCP order (runny nose, sneezing, temp over 100.1 etc.).
d. The effectiveness of the medication (follow up in 30 minutes to an hour to determine effectiveness).
*When documenting effectiveness, You MUST on a separate line write the date, time, and effectiveness of the medication. Document whether they continued to have a runny nose, were no longer sneezing, temp decreased to 98.6, etc. *
When do you NOT need two MAP certified staff signatures in the Count Book?
1. When adding a medication refill.
2. When adding a new countable controlled medication into the book.
3. After administering a dose of medication.
4. When a count sheet page is transferred.
5. When the medication storage keys change hands.
3. After administering a dose of medication.
This is when two signatures in the Count Book are required:
1. When adding a new medication or a medication refill into the Count Book.
2. When a count sheet page is transferred - including two signatures at the bottom of the completed page and the same 2 signatures at the top of the newly transferred page.
3. When the medication storage keys change hands.
4. When destroying/disposing of a medication (one MUST be a supervisor).
What should you do if you notice there is an MOR?
Check on the individual to make sure they are okay, if not call 911
Call the MAP consultant
Notify your supervisor
Document the date and time you called, the issue, what the MAP Consultant recommended, his/her name, and your full signature.
Complete an MOR report.
When discontinuing a medication on a Medication Sheet, it is a three-step process:
1. Cross out all open boxes next to where the medication is scheduled using X's or a straight line (------) may be used.
2. Draw a diagonal line through the left side box (area where the drug name, dose, strength, etc. is located). and write DC, the date and your initials.
3. ?
3. Draw a diagonal line through the right-side box (grid section) and document DC, the date, and your initials.
*This process is done for each discontinued order/medication. *
This process would also be completed for a transcription error, only instead of writing DC you would write transcription error.
What must a provider write if ordering a PRN medication?
1. Target signs and symptoms (runny nose, coughing, sneezing, watery eyes, etc.)
2. Measurable objective criteria (Temp over 100.1, No Bowel Movement in 72 hours)
4. How many hours apart doses are given.
5. ?
5. Parameters
*Parameters are needed for each PRN medication. What the plan will be if a med is given and is not effective. How many doses will be required to be administered before calling the HCP to report that it's not working, etc. *
Additionally, any PRN that is not once daily as needed, needs to state how many hours apart from other doses. For example, it CANNOT STATE twice daily as needed; it must state every 12 hours as needed.
A medication release document must be filled out every time a medication is moved from one location to another.
True or False
True
A medication release document (form) must be completed every time a medication is released from the location it is stored at.
Staff must utilize either a Release/Transfer form or a Leave of Absence (LOA) form.
Medication release documentation must include:
1. Where the medication is being transferred from.
2. Where its being transferred to.
3. The medication name and strength.
4. The total amount of medication (how many tablets, etc.) sent.
5. The signature of staff member transferring medication.
6. The signature of person receiving medication.
The original document is placed into the medication book with the corresponding month's medication sheets.
What is NOT an example of a HOTLINE Medication Occurrence?
1. Medical intervention after medication occurrence
2. Illness after medication occurrence
3. Injury/death after medication occurrence
4. Continue medication as scheduled
4. Continue medication as scheduled
A hotline medication occurrence is serious and must be taken seriously. Documentation is HUGE in what was recommended and the action steps that were taken. Make sure to document everything you did for the individual, who was notified and when.
Along with an MOR Report, DPH MUST be notified in writing via the online portal within 24hrs.
For each new Medication ordered after the start of the month is required to have Post and Verified under neath.
True or False
True
Every time a new medication is ordered it must be posted and verified underneath the medication box by two MAP certified Staff.
A medication CAN NOT be transcribed unless medication is available as Label is needed for strength and amount to be given.
Additionally, ALL HCP forms (blue, pink, yellow, green) must be posted and verified even if no new orders were given.
A copy must be made on those that have orders- the initial would go into the MAR binder as its needed to give medications and a copy would go into their medical binder as part of their record.
Telephone orders must be posted and verified twice.
once prior to sending to provider and then again once received back to verify that the provider didn't make any changes to order that was sent. If the order was changed in any way- a new telephone must be completed with the new changes and resent back to the provider for signature
What is the medication process that must be completed prior to medication administration?
1. Confirm there is an HCP order(s) for each medication to be administered.
2. Check 1- Compare the 5 rights on the Pharmacy Label to the Medication sheet then prepare the medication.
3. Check 2- Compare the 5 rights on the Pharmacy label to the Medication sheet then administer the medication.
4. Complete a silent look back.
5. Document the administration of all medication.
Who must prepare the medication for an LOA that is for more than 72 hours and is scheduled ahead?
1. A Map Certified staff
2. The Pharmacy
3. A Supervisor
4. Nursing
2. The Pharmacy
The Pharmacy must prepare all medications for those LOAs that are greater than 72 hours. Any scheduled LOA must also be completed by the pharmacy.
If you contact the pharmacy and they are unable to prepare the medication MAP certified staff can only package the LOA if:
1. It is unplanned (not scheduled ahead of time).
2. The LOA will be for less than 72 hours.
The acceptable code LOA is documented on the medication sheet for the doses/times the individual will be on the leave of absence.
An LOA form must be completed.
Any unused LOA medication that is returned to the home must be disposed of unless it is a cream, lotion, inhaler, eye med etc.
How do you prevent an MOR from occurring?
Follow the 5 rights of medication every time you administer medications and minimize distractions.
Medication information sheets are good for how many years?
1. 1 year
2. 3 years
3. Forever
4. 2 years
4. 2 years
Medication information sheets contain valuable information regarding the medication that was ordered, such as side effects. These sheets are good for 2 years and should be reordered from the pharmacy or downloaded from Drugs.com prior to 2 years expiration.
Another area to access medication information in the home is the Medication Drug Guide, which must also be no older than 2 years.
How many times must a medication be offered before it is considered a final refusal?
1. One
2. Three
3. Four
4. Two
2. Three
Types of refusals:
1. Person says "No".
2. Person spits the medication right back out or never takes the medication from you.
3. Person spits the medication out later.
4. Person intentionally vomits the medication within one half hour of taking it.
Where must you document the disposal of medication?
1. The Medication Administration Record
2. The Count Book
3. The DPH Disposal Record Form
4. The Ordering and Receiving Log
3. The DPH Disposal Record Form
All controlled and countable controlled medication to be disposed must be documented on the DPH Disposal Record Form.
When a countable controlled medication is destroyed, the Disposal Record and the Count Book documentation must agree and signed by the same two staff members (One who is a supervisor).
Reasons for medication disposal:
Refusals
Med was dropped on the floor
Med was discontinued
Med is expired (outdated)
Medication was prepared incorrectly
The person no longer resides at the agency (or has passed away)
The supply of medication in the program is more than allowed
Is an unused LOA medication
What form is used to track and document on for an MOR?
A Medication Occurrence Report (MOR) form
Every time an MOR is reported it is a way to help improve and prevent another MOR occurring the same way. It is a way to safeguard those we care for and preventing an MOR from occurring.