medication administration check off

step 1

perform a detailed chart review

step 2

FACE Chart for name, date of birth

step 3

patient history tab to review past medical history, allergies, labs(ELECTROLYTES), And admitting diagnosis

step 4

review nursing worksheet for vital sign trends specifically blood pressure

step 5

check orders in MAR tab (1st 5 Right: PATIENT, drug, dose, time, route)

step 6

gather supplies for medication administration (Stethoscope, blood pressure, cuff, and medication in the med cart, and two med cups)

step 7

compare MAR with actual medication (Perform second of the 5 rights: Patient, DRUG, dose, time, route)

step 8

place medication in first medication cup

step 9

Close screen for patient privacy

step 10

hand washing and hand Sanitize

step 11

knock on door

step 12

introduce self

step 13

Close curtain for patient privacy

step 14

hand sanitize

step 15

Open laptop

step 16

verify, patient name and DOB and MRN verbally, confirm with chart and wristband

step 17

verify allergies, verbally, check with chart and wristband

step 18

asses for pain

step 19

explain reason for visit (I’m going to be giving you your medication, This Medication is a diuretic, which can lower your blood pressure and cause dizziness if you’re standing alone due to a loss of electrolytes)

step 20

position patient in an upright position

step 21

get patient consent

step 22

A&O x4

step 23

check bp

step 24

elevate bed for assessment

step 25

perform assessment: Swallow test, gag, reflex, cough reflex

step 26

verify for a second time, patient name and date of birth and allergies

step 27

perform a 5 rights: Patient, drug, dose, time, route at bedside between MAR and medication

step 28

Scan medication and wristband of patient

step 29

hand sanitize

step 30

Open medication and place in a second medicine cup

step 31

administer medication and confirmed patient swallowed medication

step 32

immediately document medication given

step 33

leave bed in the same position

step 34

reassess for pain, provide call bell, ask patient if they have any questions, let them know you’ll be back in 30 minutes, hand, hygiene, and sanitize