Answer:
When documenting and reporting unadministered medication, it is crucial to include specific details to ensure accuracy, accountability, and patient safety. Here are some key elements to include in the documentation and reporting of unadministered medication:
1. **Patient Information:**
- Patient's full name
- Patient's identification number or medical record number
- Date of birth
- Location or unit where the patient is receiving care
2. **Medication Details:**
- Name of the medication (generic and brand name, if applicable)
- Dosage strength
- Dosage form (e.g., tablet, liquid, injection)
- Frequency of administration
- Reason for the medication (e.g., treatment, symptom management)
3. **Reason for Non-Administration:**
- Clearly document the reason why the medication was not administered. Common reasons include:
- Patient refusal
- Allergy or adverse reaction
- Medication not available
- Incorrect medication or dosage
- Prescriber's order to withhold the medication
- Patient transferred or discharged
4. **Documentation Time and Signature:**
- Date and time of the non-administration
- Signature or initials of the healthcare provider who verified and documented the non-administration
5. **Follow-Up Actions:**
- Any follow-up actions required, such as notifying the prescriber, documenting in the patient's medical record, or scheduling a reassessment of the medication plan
6. **Reporting Procedure:**
- Follow the facility's protocol for reporting unadministered medication, which may involve notifying a supervisor, pharmacist, or appropriate team member.
By including these details in the documentation and reporting of unadministered medication, healthcare providers can maintain accurate records, ensure patient safety, and facilitate continuity of care. If you have any more questions or need further assistance, feel free to ask!
