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.
check 1- is posting
check 2- verifying
must include both staff's full signature, the date, and 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 a MOR
Depending on the error it can cause something called a Medication Hotline, where the individual requires medical attention due to one of these 5 rights not being followed.
Which one of these following answers is NOT correct regarding the sections in a count 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 count book.
these books must be used when there is a controlled substance medication in the home
there needs to be a shoulder-to-shoulder count at least every 24 hours but should be done every time the shift changes and another MAP certified staff comes on.
A medication occurrence occurs when one of the 5 rights are not followed
True or False
True
Wrong:
person
Medication
Dose
Time/ Omission
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
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 needs to be written on the back of the MAR stating:
the date
the time
the reason you gave the medication- must be one of the reasons to give on the HCP order (runny nose, sneezing, temp over 100.1- give actual temp)
the effectiveness of the medication- such as will follow up in an hour or two hours to determine effectiveness
*YOU MUST after the time you written one -two hours for example- must come back and in a separate line write the date/ time/ and what you found when you rechecked- no longer had a runny nose, no longer sneezing, temp is now 96.8, etc.
1. adding a medication refill
2. adding a new countable controlled medication to the count book
3. After administering a dose of medication
4. a count sheet page is transferred
5. 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. adding a medication refill
2. adding a new countable controlled medication to the count book
3. 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
4. the medication storage keys change hands
What should you do if you notice there is a MOR?
Check on the individual to make sure they are okay, if not call 911
Call the MAP consultant
Notify your supervisor
document what the MAP consultant states, date/ time you called, the issue, what they recommended, their name, and then your name and date/time
complete a 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 you initials.
*This process is done for each discontinued order/medication.
This process would also be completed for a transcription error- only instead of DC it would state transcription error
How must a provider write if they are 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 is needed for each PRN medication- what is the plan if and when it is given, it's not effective. Dose the provider wants us to give it for 4 doses then call them if 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. IT CAN NOT STATE twice daily as needed; it would need to state every 12 hours as needed, or every 6 hours, every 8 hours, etc.
True or False
True
A medication release document (form) must be done every time a medication is being release from the location it current is at.
Must use: release forms/ LOA forms
A MAP certified staff must be the one to transfer the medication to the receiving location such as day program
Medication release documentation must include:
where the medication is being transferred from
where its being transferred to
medication name and strength
total amount of medication (how many tablets, etc.)
signature of person transferring medication
signature of person receiving medication
copy goes into the LOA binder to keep track of
What is a NOT 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 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 and who was called and notified when
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 are the 3 checks of the 5 rights that must be completed prior to medication administration?
1. Check 1- compare the 5 rights on the HCP Order to the Pharmacy Label
2. Check 2- Compare the 5 rights on the Pharmacy Label to the Medication sheet
3. Check 3- Compare the 5 rights on the Pharmacy label to the Medication sheet
Who must prepare the medication for a LOA that is for more than 72 hours and that is scheduled ahead
1. Map Certified staff
2. Pharmacy
3. Supervisor
4. Nursing
2. Pharmacy
The Pharmacy must prepare all medications for those LOAs that are greater than 72 hours. Any scheduled LOA must be completed by the pharmacy also.
If you contact the pharmacy and they are unable to prepare the medication MAP certified staff can only package the LOA if:
1. unplanned (not scheduled ahead of time)
2. Less than 72 hours for LOA
LOA is documented on the medication box for the doses/times the individual will be LOA
A LOA form must be completed
any unused LOA medication that is returned to the home, must be disposed of unless it is a cream or lotion, etc.
How do you prevent a MOR from occurring?
Follow the 5 rights of medication every time you administer medications and reduce distractions
Medication Information sheets are good for how many years?
1. 1 year
2. 3 years
3. forever
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, prior to 2 years expiration.
Another area to access medication information in the home is the Medication Drug guide, which is also updated every 2 years.
How many times must a medication be offered before it is considered a final refusal?
1. once
2. three
3. four
4. twice
2. three
types of refusals:
1. persons says "No" try again in a few mins.
2. spits the medication right back out or never takes the medication from you
3. spits the medication out later
4. intentionally vomits the medication within one half hour of taking it.
*Documentation of a refusal on the MAR
your initials circled on the MAR on the dose you tried to give
a progress notes on the back of the MAR stating why the medication wasn't administered, recommendations given, and who was notified (HCP and supervisor)
Where must you document a disposal of medication?
1. MAR
2. Count book
3. DPH Disposal Record form
4. Ordering and Receiving log
3. DPH Disposal Record form
All controlled and countable controlled medication to be disposed must be documented on the DPH Disposal Record Form.
when the countable medications are disposed the disposal record, and the count book documentation must agree- the reason must be in both places
reasons for medication disposal:
refused
dropped on the floor
was discontinued
expired (outdated)
medication was prepared incorrectly
the person died
the supply of medication in the program is more than allowed
unused LOA medication
What form is used to track and document on for a MOR?
Medication Occurrence Report (MOR) form
Every time a 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 a MOR such as a Hotline from occurring