Information that a medication administration record includes are the patient's information, a drug name and the dosage, reports Assessment Technologies Institute. It must also include the medication route, the time and the assessment information that a nurse collects during administration, such as blood pressure. The record also includes the nurse's initials, the patient's response to the medication and if any medications were withheld and the reasons for withholding medications, if applicable.
The medication administration record can be in paper form or computerized form, which sometimes uses a bar-code system, according to the Assessment Technologies Institute. The pharmacy department usually creates and distributes the medication administration record every 24 hours. If there is a medication error, a nurse must fill out a medication incident report that includes the patient information, description of what happened and the patient's condition. The nurse's signature must also be on the medication incident report.
Some health care providers use computerized charting and medication administration records, notes Assessment Technologies Institute. A computerized medication administration record is beneficial because providers can view all of a patient's information in one location, including admission and discharge information. When a nurse uses the bar-code method, she scans her identification badge, the patient's identification bracelet and the bar code on the medication label with a handheld scanner. The scanner then sends the information to the computerized medication administration record.