Does my med pass technique sound sufficient?? I need tips

[curlywurly]

I am a third semester student in my ABSN, and am working on perfecting my med pass so here is what I do, please correct me if needed.

By the way I do the 6 checks 3 times

1) Check what meds are due and make sure it makes sense to pull/give these meds. Check what order instructions there are and if any assessments are needed. 

2) Pull from the pyxis 

3) Check meds/prepare them outside room

4) Go in room with meds ready, verify pt and allergies, inform pt of meds I am giving and if I have not assessed what I needed yet check those and hold any meds that don't meet parameters

5) Give meds with appropriate route/per order

6) Sign meds as given

I make sure they take the meds.

My question is more on technicalities, what if they refuse the med before I scan it in? could I correct that without it being scanned in as refused or hold it??

Please share any advice as I am wanting to be as safe as possible throughout this process, thank you!

[Julia Liou, RN]

It is great that you are asking these questions and ensuring safety! Are you a nursing student or getting orientated on your unit? The workflow process may vary depending on hospitals, so the best person to ask about holding versus documenting refusals would probably be your educator. If you're still a student, you can ask your clinical instructor. 

It also varies depending on if you're paper charting, using a device to scan meds, or charting directly on EMR. If a patient refused in my hospital, we'd just document it as refused, not hold the medication. On our device, there is an option to record it as patient refused.