MEDICATION ADMINISTRATION
CREDENTIALING, TRANSCRIPTION,
ADMINISTRATION & DOCUMENTATION
SECTION
Replaces
Policy
Date
Effective
Revised
Reviewed –
no revisions
Applicability
e.g., RN, Respiratory
Therapy, Medical
Assistants, PT,
Radiology and ECHO
Tech. Pharmacy,
Providers and IT
Page 1 of 4
Eileen Skinner, President/CEO
Date
Mercy Value: Excellence
We strive for the highest standards of care for our patients’ physical, mental, and spiritual
needs.
Additional Policy Reference(S):
 Allergy Management
 Automated Dispensing Machine Guidelines (ADM)
 Computerized Unscheduled Downtime Medication Record
 Dosing Windows
 Medication Orders
 Methadone for Short-Term Detoxification
 Patient Identification
 Range Orders
 Removing Medications from an Automated Dispensing Machine and Medication
Overrides
 Standard and Transmission Based Precautions
PURPOSE
To describe safe medication transcription, administration, and documentation practices.
POLICY
1) Medications may be administered by employees of Mercy Health System of Maine who are
authorized by a licensing agency of the State of Maine and deemed competent by Mercy
Hospital to administer medications and monitor medication effects.
 Medical Staff and Health Professional Affiliates
Members of the Medical Staff and Health Professional Affiliates (e.g. nurse practitioners,
physician assistants) may administer medications within the scope of their license and
consistent with the Medical Staff Rules and Regulations and in compliance with the hospital
and Medical Staff Bylaws. Health Professional Affiliates must be properly supervised.
 Registered nurse and licensed practical nurses currently licensed by the Maine State
Board of Nursing may administer medications as described in hospital policies and
according the Maine State Board of Nursing’s “Nursing Rules”. Nursing students
may administer medications under the supervision of a nursing instructor or staff
nurse.
 Other Staff
Medications may be administered by other staff who is authorized by their respective
licensing agencies and who are approved by department managers according to the
standards and competencies of the department. These staff include respiratory
therapists/technicians, radiology technicians, physical therapists, and ECHO technicians.
Drugs/Approved routes of administration:
Registered Respiratory Therapists and Technicians: Nasal cannula oxygen, endotracheally,
inhalation mask, nebulization, and metered dose inhaler, intranasal, bronchoscope,
intramuscular and subcutaneous.
Physical Therapists: topical, phonophoresis, and iontophoresis
Radiology and MRI Technicians: Contrast agents
ECHO Technicians: Intravenous flush.
Medical Assistants: Oral, intramuscular and subcutaneous
Nuclear Med Technologists: Intravenous and subcutaneous
2) Drugs and biologicals must be prepared and administered in accordance with Federal and
State laws, Mercy Hospital policy, the orders of provider or providers responsible for the
patient’s care, and accepted standards of practice.
3) Medications may not be administered unless the medication order has been reviewed and
verified by a pharmacist OR medication prescription, preparation, and administration are
under licensed independent practitioner authorization and control OR it is a medical
emergency where the delay resulting from pharmacist verification of the order might result in
physical or psychological patient harm.
4) The patient’s height, weight, and allergies must be available in Meditech except for Mercy
Primary Care Patients who will have their allergies recorded manually.
5) Stat and Now orders are processed immediately by the Pharmacy or E-PharmPro
6) Stat medications are due within 30 minutes of prescription, now orders within 1 hour, and all
other orders are due according to Dosing Windows.
7) Bedside Medication Verification (BMV) must be used as part of the medication
administration process whenever possible.
8) Medications are administered according to established practice guidelines including
Standard and Transmission Based Precautions and the Medication Administration Standard,
with particular attention to the Five Rights.
INPATIENT PROCEDURE
1. New medication orders are faxed to the pharmacy.
2. The pharmacist reviews the medication orders for allergies; drug and food interactions;
appropriateness of dose, frequency, and route of administration; laboratory values;
therapeutic duplication; compatibility with hospital policy; and contraindications.
Questions are resolved with the prescriber prior to placing the medication order on the
Medication Administration Record (MAR).
3. The clinician verifies all new MAR entries against the medication orders and
acknowledges the entry on the MAR.
4. The clinician rejects orders that are incorrectly transcribed on the MAR and enters the
reason for the rejection.
5. The clinician signs the Physician Order Sheet in the column “Action Taken” before
administering a dose of medication.
6. When medications are administered, the nurse reviews the MAR and the Automated
Dispensing Machine (ADM) profile.
7. The nurse:
8. Obtains/reviews prescribed parameters such as blood pressure, blood sugar, or injection
sites
9. Compares the patient’s allergy profile to the medication(s) to be administered
10. Removes medications from the ADM
11. Prepares the medication for administration
12. Brings the computer and BMV wand to the bedside
13. Verifies the patient’s name and date of birth
14. Tells the patient the medication name and indication
15. Accesses the MAR
16. Scans the patient identification band (point the guide light on the barcode and squeeze
trigger)
17. Scans the medication
18. Reads all messages and takes appropriate action
19. Evaluates data and completes assessments
20. Scans additional medications, if any
21. Administers the medication(s)
22. Uses the FILE/SAVE function to save the MAR documentation.
23. If a range of dosing is ordered (e.g., 25-50 mg), the dose given is documented next to
the time of administration.
24. If a medication is omitted for any reason (e.g., patient refusal to take the medication), a
non-administrative reason must be documented. A note and additional comments must
be recorded if required. Notify the prescriber as indicated.
25. When a medication has been given outside of the scheduled administration time frame,
an administrative comment must be documented.
26. Intravenous solutions are documented each time a bag is hung.
DOWNTIME DOCUMENTATION
 Bedside Medication Verification Scanning will not be required with back-entry of data
due to a Downtime
 Medication administration during electronic record Downtime must be back-entered by
the nurse. When data is entered by a caregiver other than the original nurse
administering the medication, the paper downtime MAR will be saved as part of the
medical record.
OUTPATIENT PROCEDURE
A. All Express Care Locations:
1) Provider writes the order
2) If the medication is a high alert medication or a pediatric dose should be double
checked by a second nurse or provider
3) The medication is obtain from the (ADM)
4) The clinician administers the medication based on the five rights of medication
administration.
5) After medication is administered the clinician signs off the original order and writes a
comment in the notes section to address the route, time and response to the medication.
B. Oncology/Hematology Outpatient Clinic
1)
2)
Provider writes the order or signs off the standard order sheet.
Faxed to pharmacy.
3)
4)
Pharmacy enters orders.
Nurses either receive medications from pharmacy or remove them from the (ADM).
5)
If the medication is chemotherapy two nurses check the calculation based on the Body
Surface Index. Then the two nurses sign off on the order sheet.
The nurse verifies the right dose, route, time, drug and patient. Then administers the
medication.
At the end of the day the medications are signed off in the patient’s medical record.
6)
7)
PEDIATRIC CONSIDERATIONS:
1) a) All pediatric patients will have their weight measured in kilograms using a pediatric scale.
b) All pediatric patients will have a weight specific Micromedex PALS dosing information
guide placed in the medical record when entering the emergency department, ACU, and all
inpatient surgical units. The dosing information will be placed in the front of the patient
record and remain with the chart until the patient is discharged. Please see appendix B for
directions to access Micromedex.
c) The registered nurse calculates all pediatric doses whenever a calculation based on
body size is used to determine dose.
d) Any child under 10 years of age have a second registered nurse verify the calculation
when administering medication in the emergency room, ACU, OR, PACU and the Inpatient
surgical units. At the Express Care locations in the absence of a second nurse, a provider
may double check pediatric doses. Nurse or provider verifying the medication must
document a note or memo in the patient’s record that the calculation of the medication was
completed.
e) An oral syringe must be used when administering liquid medication.
REFERENCE(S)
1. Resources for Pediatric Dosing include Harriet Lane and Neofax
2. Preventing pediatric medication errors, The Joint Commission April 2008,
www.jointcomission.org.
3. 2009 Hospital Accreditation Standards, The Joint Commission. MM.06.01.01 The
hospital safely administers medications.
4. Maine State Board of Nursing, Nursing Rules
http://www.maine.gov/boardofnursing/rules_files/rules.html#rules
5. CMS Conditions of Participation for Hospitals 482.23 Preparation and Administration of
Drugs, 10/2008.
6. American Academy of Pediatrics
This policy/procedure is only intended to serve as a guideline to assist staff in the delivery of
patient care; it does not create standard(s) of practice. The final decision(s) as to patient
management shall be based on the professional judgment of the healthcare provider(s) involved
with the patient, taking into account the circumstances at that time
MERCY HOSPITAL POLICIES AND PROCEDURES
POLICY DEVELOPMENT HISTORY
Policy Name
Medication Administration: Credentialing, Transcription,
Administration and Documentation
Policy Location
Patient Care Services -Pharmacy
Principal Contact
Susan Fraser, Pharmacist
Originating Manager
Reviewed by
(Individuals, committees)
Practice & Quality Council
Date of
Review
Pharmacy and Therapeutics
5/19/10
Nature of revision
NEW POLICY
3-year review: no changes needed
Minor revisions only (no description required)
Major content revisions (briefly describe
below):

Merged a new Medication Administration
policy and the transcription, administration
and documentation policy.

Added outpatient procedure for medication
administration.