What is required in documenting the time a medication is given?
For medications with regularly scheduled doses, you may use the regularly scheduled time as long as the medication is given within thirty minutes of the scheduled time. Otherwise, you must document the actual time the medication is given. Example: For a regularly scheduled 9:00 a.m. medication given at 9:20, you may document 9:00 a.m.; if the medication is given at 9:45, then you must document 9:45 a.m. If you document the time by initialing the regularly scheduled time (pre-printed on the form), there must be a space on the form to document the time given when it is outside the 30-minute window. For medications that are PRN or one-time only, you must document the exact time the medication is given.
