Med documentation

Reigen · Sep 1, 2012

When finding an unusal doseage, if not comfortable inadministering, one should call and speak to the person who made the order, and clarify the reason(s) for that particular doseage. Calling pharmacy is also an option, as the pharmacy may have already clarifed with the person who ordered that dose. Documenting speaking with either the orginal ordering person and the pharmacy , and reporting these conversation to the on coming shift/nurse would also be good.

I hope this helps

KelRN215, BSN, RN · Sep 2, 2012

"Unusual doses" of meds were an every day occurrence with my first job. With new anti-epileptics hitting the market regularly, they were seen as a "new hope" for kids whose seizures had been medically refractory. None of these new drugs were FDA approved in children. I've given doses of certain meds to children that were triple the maximum daily dose for adults recommended by the FDA. Did we call to question it before every dose? No, because it had already been discussed with the MD and the pharmacist upon the writing of the original order and this particular institution was studying increased doses of the medication in question.

I would also say it depends on the situation. 100 mg of morphine/hr is an unusual dosage for an 8 yr old 24 kg child (it's 100x the dose he was on when we began the continuous infusion) but I've given it before... the child was imminently dying on comfort measures only and the dose was escalated over several days. It was of course documented that the child was a DNR and on this dose to keep him comfortable but this medication was given continuously, it certainly wasn't documented repeatedly.

loriangel14, RN · Sep 2, 2012

What do you mean by "unusual"? Do you mean PRN meds? Yes I would document my assessment.

Stoogesfan · Sep 3, 2012

What do you mean by "unusual"? Do you mean PRN meds? Yes I would document my assessment.

That's the exact wording on the question. I "think" it meant the dosage is unusual dose...like usually it'd be 0.5 mg and the order was 0.8 or something? I'm not real sure though.

loriangel14, RN · Sep 3, 2012

That is a very vague question they have posed.

classicdame, MSN, EdD · Sep 4, 2012

Vague question, but I would answer yes. The nurse should document anything out of the ordinary. In this case, the nurse would be responsible for administering the med and should be able to document he/she conferred with the MD, the pharmacy and was told the dose was therapeutic but not toxic, or something to that effect. Otherwise, it will look like the nurse just gave the wrong dose without question.

Stoogesfan · Sep 5, 2012

Well we reviewed tonight and according to our instructor the answer is no. She didn't really give clear rationale about why but she said the "best answer" was no.

Esme12, ASN, BSN, RN · Sep 6, 2012

I will not argue with your instructor. But I will tell you that it may not be "against the law", per say, not to document the dosage......... it is legally the prudent thing to do in the real world. If the patient suffers an untoward event that winds up in court and you have not documented the exception.....why you gave a dosage other than the dosage ordered....you will be held liable and negligent. Document the exception.....other wise.....are you playing the doctor and practicing medicine?

Unusual occurrences and patient injuries need to be documented. Objectively document what you witness without making any conclusions or unsubstantiated assumptions. Document the patient, roommate or visitor comments. Record the patient’s vital signs, physical condition, mental condition, subjective complaints, physician’s notification and arrival, and details of treatment. However, do not mention that an incident report or occurrence report was filled out. Always chart patient’s uncooperative behavior. For example, these behaviors include:
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[TD]leaving against medical advice,
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[TD]refusing or abusing medications;
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[TD]failing to follow diet or exercise plan,
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[TD]patient or family tampering with traction, IV’s, monitors,
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[TD]failing to follow-up with visits to clinic or physician, or
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Document any safeguards or other preventive measures you are taking to protect your patient (side rails in place; call light available, etc.).
Chart that the facility’s safekeeping system was explained and made available to the patient. Encourage patient/family to have valuables sent home. If they agree, have them sign their names next to a documented statement to that effect. Discuss the availability of a safe and make sure that all items put in safe are recorded on a receipt complete with the patient’s name and ID number. Describe each item in detail, using objective language for example yellow ring with clear stone instead of charting a gold diamond ring. Update valuables list frequently for long-term patients. Before a patient is transferred, take an inventory of the valuables list to verify location of items.
Document medication administration in as thorough a manner as possible. Note the date, time, your initials, the method of injection (IM, SQ, etc.), and the site of the injection.

When recording intravenous (IV) infusions note the site of infusion; type and amount of fluid; medications added; and administration rate. At least once a shift, note the condition of the IV site and type and size of catheter. Use three separate lines when transcribing orders on the medication administration record. Reserve the first line for the drug name and dose, the second line for the number of tablets or capsules along with the strength of each and the third for administration route, frequency, and additional information.

If a medication is given for pain, note the site of the pain and its severity. Then follow up, noting the effectiveness of the medication. When omitting a medication, document the rationale. For example, “pain medication held pending stabilization of vital signs.” If a medication order is being questioned, tactfully document your conversation with the doctor. If someone else is giving your patient medication while you are off the unit, make sure that person charts the administration.

http://www.ceufast.com/courses/viewcourse.asp?id=44#Legally_defensible_charting_guidelines

Stoogesfan · Sep 6, 2012

I will not argue with your instructor. But I will tell you that it may not be "against the law", per say, not to document the dosage......... it is legally the prudent thing to do in the real world. If the patient suffers an untoward event that winds up in court and you have not documented the exception.....why you gave a dosage other than the dosage ordered....you will be held liable and negligent. Document the exception.....other wise.....are you playing the doctor and practicing medicine?
http://www.ceufast.com/courses/viewcourse.asp?id=44#Legally_defensible_charting_guidelines

She wasn't saying we gave a dose different than the order. She said it was like the dr ordered 0.7 mg but the common dose would be 0.5 mg and we gave the ordered 0.7 mg we wouldn't document rationale for giving the ordered dose.

allnurses Guide · Sep 7, 2012

She wasn't saying we gave a dose different than the order. She said it was like the dr ordered 0.7 mg but the common dose would be 0.5 mg and we gave the ordered 0.7 mg we wouldn't document rationale for giving the ordered dose.

I agree, unless the abnormal dosage was greater than the max dosage in which case, for the first time giving the med, I would verify with both the pharm and the prescriber and document as such.

Example: IV Tylenol for a 6 year old that was greater than 15mg/kg.

NicuGal, MSN, RN · Sep 8, 2012

We document who it was cleared by if it is outside of our guidelines, but we don't document the rationale, the doctors should be putting that in the note.