Where and how is a medication error to be documented in the service recipient’ s record?
Medication error forms or incident reports are not to be kept in the service recipient’s record. The medication given or omitted should be recorded on the medication administration record. Any consequences that result from the medication error should be noted in the staff communication notes, as well as, resulting staff interventions or actions. Staff communication notes should be brief and factual without omission of guilt or error. Staff communication notes should not reference that a medication error or incident report was completed.
Related Questions
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- Where and how is a medication error to be documented in the service recipient’ s record?
