DD Register

[magicbutton]

Hi

what is the policy at your hospital for recording when giving drugs out for PCA in columns 'Drug Used' and 'Amount Administered' There are several ways of writing the drug up.

Do you write up the dose prescribed for pt 90mg or 30mg as on the 30mg Morpine page as part of a 100mg order - as to not to 'confuse' anyone? Different standards are conffusing there should be National Standards.

2 other issues

What do you use the comments column for if anything our Level 2 insists on PP for Pain Protocol - is this necessary?

How do you document disgarded drug and where please?

Any comments would be helpful. Thanks so much

[GHGoonette, BSN, RN]

The scheduled drug register is a legal document. After any incident adversely affecting a patient where there is reason to believe that drugs administered may be the cause, the information in the register will be required as evidence. It is therefore essential that all records be accurate. You don't mention your country, but in mine the patient details, prescribing doctor, amount given and the signatures of the persons administering and checking are entered on one line, and the amount discarded on the next line.

Protocols regarding the correct maintenance of registers should be covered by whatever laws exist in your country regarding the storage, issuing, recording and checking of controlled substances. If you google it I'm sure you'll find it.

Obviously, entries are made on the page of the specific ampule used; for example, if an anaesthetist opens a 50ml Propofol and only uses 20ml, the entry will be made on the page for the 50ml vial, as opposed to that for the 20ml ampule; if he gives Pethidine 50mg using a 50mg ampule, and afterwards gives a further 50mg, also using a 50mg ampule, the register must reflect two 50mg ampules administered, as opposed to one 100mg ampule. Otherwise your daily checks will be horribly wrong.