The right documentation during and after a med pass is of the utmost importance. Remember, if it is not documented, it is not done! Always document the meds given AFTER they have been given. If you document before, and the resident refuses or spits out the med, you have a lot more steps to completing your paperwork.
Remember to use the Nursing Process (nursing 101): Assessment, Diagnosis, Planning, Implementation and Evaluation. The assessment includes vital signs, lung and abdominal sounds, and adverse reactions to medications. Your documentation is your proof of care provided to each resident.
The nurse has two hours to complete the medication pass. Ask the floor staff to go to the supervisor with questions as med nurses should not be interrupted during the pass. Check the MAR for the times medications are due. After each patient, enter the drugs given. If you have a missed dose, wait until the end of the pass to get the med. If a PRN is given, mark the time, dose, reason and then go back after 1 hour to recheck the effectiveness. For pain medications, don’t forget to document the level of pain, as well as the pain level after 1 hour.