What must be included in my medical record documentation when administering medication(s)?
Medical record documentation should include the name of the medication, the dosage and the route of administration. The site of the injection should also be documented in the patient’s medical record and should include any patient reactions to the medication and a signature of the person administering the medication. Documentation must be maintained in the patient’s chart to support the medical necessity of the injection given. When a portion of the drug is discarded, the medical record must clearly document the amount administered and the amount wasted.
