Kamis, 24 April 2008

Documenting oral drug administration

After administering a tablet or capsule, be sure to record:

  • drug given
  • dose given
  • date and time of administration
  • signing out of the drug on the patient's medication record patient's ability to swallow the drug you administered (if the patient has had problems swallowing oral drugs)
  • patient's vital signs if you give a drug that could affect them
    adverse reactions that arise
  • patient's refusal and notification of a health care provider as needed (if a patient refuses a tablet or capsule) omission or withholding of a drug for any reason.
Source: Fundamentals of Nursing made Incredibly Easy!, Lippincott Williams & Wilkins, 2007.