Charting Medications

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Can we change the time medication is administered when charting?

If a medication is given late is it proper to change the time to when it was due and chart medication administered in a timely manner late entry due to resident cares?? I noticed many older nurses doing this…or leaving the meds uncharted or refused if they don’t know if they were administered.

Tenebrae, BSN, RN

1 Article; 1,806 Posts

Specializes in Mental Health, Gerontology, Palliative. Has 11 years experience.

When I've given a med beyond the time it was due, eg delayed for patients having ECT, any other procedure requiring nil by mouth or simply a patient refusing to get up earlier and take meds when they are due I sign it at the time it was given and a reason eg patient previously NBM until after procedure. 

JKL33

6,465 Posts

6 hours ago, thisnurse123 said:

If a medication is given late is it proper to change the time to when it was due and chart medication administered in a timely manner late entry due to resident cares??

If I understand what you're saying, no.

Just chart the time it was given; okay to make brief notation of reason for delay.

Specializes in Critical Care. Has 8 years experience.

medication administration needs to be documented in real time to prevent medication errors. If a medication is administered late it is prudent to include a comment explaining the situation; I.e. Vancomycin 1000mg/200ml administered at 23:15 due to IV medication incompatibility with previous antibiotic. If the medication is administered at a much later time than scheduled, then the provider should be notified and a request to pharmacy to retime medication's next dose; at least that's my practice. 

thisnurse123

27 Posts

13 minutes ago, Okami_CCRN said:

medication administration needs to be documented in real time to prevent medication errors. If a medication is administered late it is prudent to include a comment explaining the situation; I.e. Vancomycin 1000mg/200ml administered at 23:15 due to IV medication incompatibility with previous antibiotic. If the medication is administered at a much later time than scheduled, then the provider should be notified and a request to pharmacy to retime medication's next dose; at least that's my practice. 

Agree I guess it’s different in LTC

Specializes in Occupational Health. Has 19 years experience.

what you're describing sounds like falsifying documentation....and no....it's not acceptable.

thisnurse123

27 Posts

2 hours ago, sleepwalker said:

what you're describing sounds like falsifying documentation....and no....it's not acceptable.

Thanks this is just how I noticed they are charting in the long term care facilities 

kbrn2002, ADN, RN

3,729 Posts

Specializes in Geriatrics, Dialysis. Has 21 years experience.
19 hours ago, sleepwalker said:

what you're describing sounds like falsifying documentation....and no....it's not acceptable.

 

17 hours ago, thisnurse123 said:

Thanks this is just how I noticed they are charting in the long term care facilities 

sleepwalker is correct, changing administration times in the MAR just to make it look like meds were given on time is definitely falsifying documentation and is at best a very slippery slope to other corner cutting dangerous practices and at worst grounds for termination and reports to the BON. Plus the potential does exist although it is admittedly small for adverse effect to the resident. If you are noticing this is how it's done in LTC you are not working in the right LTC. I worked LTC for 25 years and never saw fudging times in the MAR as a standard practice.

On 11/30/2022 at 4:23 AM, thisnurse123 said:

Thanks this is just how I noticed they are charting in the long term care facilities https://diggy.games/

The repetition of data gathered from various assessments is a frequent issue seen in long-term care records.

Specializes in ED RN, Firefighter/Paramedic.

Epic - Reason for off schedule - “Nurse decision”.  “Priority of care” goes in the comment box.

 

Specializes in Critical Care. Has 8 years experience.
6 hours ago, FiremedicMike said:

Epic - Reason for off schedule - “Nurse decision”.  “Priority of care” goes in the comment box.

 

My favorite comment to use workload priority or bundled care for when meds are scheduled at 0800/2000, 0900/2100, and 1000/2200 😬