Which of the following should the nurse use to document medication administration?

Question

1. Erase each medication from the MAR immediately after administration.
2. Record time administered and nurse's name at once after administration.
3. Record medication administration time, route, and dosage at end of shift.
4. Delegate recording administration time and the nurse's name in the MAR.

Answer 1

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2. The nurse records the nurse's name and administration time immediately after me-dication administration to maintain an up-to-date and accurate client medical record. If the nurse plans the event but it did not occur, the nurse cannot document the event because documentation records events, statements, tests, etc., that have occurred. In addition, documentation follows medication administration in a logical order; the nurse assesses the client first, administers the medication if indicated, documents the assessment with the administration, and performs postadministration assessments.
3. Documenting at the end of the shift is risky practice because the chance of a do-cumentation omission increases with the amount of time that passes. In addition, the nurse owes a duty to the client to document medication immediately after administra-tion to avoid client injury, overdose, and confusion and to maintain current and ac-curate medical records.
4. The nurse avoids delegating medication documentation to anyone, even another nurse. The only person who documents for an individual nurse is the individual.