How do I document Medication Administration?

Medication Administration: Documenting Packed Medication Administered and Not Administered

Administration of Packed Medication

  1. After successfully administering a medication to your resident,  simply click the check box (tick) next to the medication name

  2. Type any notes relevant to the Administration into the Notes field
  3. Enter your password or PIN
  4. Click Sign

  • After successful administration, the medication drops down the Packed Medications list and is marked as Done

Non Administration of Packed Medication

  1. If the medication cannot be administered, simply click the X button

  2. If the medication was refused, select this option (Refused-R)

  3. Enter Notes into the Notes field
  4. Then click Sign
  5. You will be prompted to enter your password/PIN

  6. Then click Sign
  7. The medication that was not administered  will drop down the Packed Medications list, and the Dose Omitted Code will display

  8. In the event you have made an error, simply click the Undo button. The documentation will be cleared and the medication will again appear at the top of the medications list
  9. If all Packed medications were successfully administered, click the tick next to All and all medications will be marked as Done
  10. You will be prompted to enter your password/PIN
  11. Then click Sign
  12. All medications are now marked as Done
    You may also mark that all Medications were not administered.
  13. Simply click the X button next to All
  14. Select the relevant Dose Omitted Code
  15. Enter any relevant notes into the Notes field
  16. Then click Sign.
  17. You will be prompted to enter your password
  18. Then click Sign
  • Scroll down to view other types of categories of medications that are to be administered in this round
  • Other medications requiring Action include S8s, Insulin and Non-Packed Medications
  • Some medications may be marked as No Stock is Available

This is an example of how the Drug Register directly interacts with the administration round. The medication will need to be added to the Drug Register before administration can be attempted.

After you have received and recorded delivery of the medication from the supplier  – ‘Stock is now available’ will be written next to the medication.

(Also refer to Administering Patches and Nurse Initiated Medications)