When learning how to give medications in a simulation or skills lab, it’s important to have a realistic EHR for education. After all, one of the most tested-on aspects of Medication Administration is verifying a medication against the order, verifying the medication matches the patient, and charting any medications given.
In order to make this process as realistic as possible, we suggest an academic EHR for simulation. Specifically, ChartFlow.io, but we’ll admit we’re biased,
What is a Medication Order and where to find it?
If using an EHR/EMR, you will usually have both an “Orders” tab and a “Medication Administration Records/MAR” tab on the navigation menu. In ChartFlow, both of these are on the left-hand side of the screen. The Orders section will typically include every medication and non-medication order for the patient. The MAR will usually include all the medication orders arranged on a schedule. The MAR is where you will chart any medications given.
Orders:
MAR:
Now for the important part: Every order should include the following:
If a medication order does not have this information, you should always check with a higher level provider for clarification. Thankfully, missing information is rare in an EHR considering you can’t save an entry without filling out all required fields, but as a Medication Aide or Nurse you’ll still be required to know what to look for:
- Date and time of order
- Name of the medication ordered
- Name/signature of the Physician or Mid-Level Provider who entered the information
- Dose ordered
- Route (oral, sublingual, IV, etc.)
- Form (syrup, tablet, capsule, etc.)
- Frequency and time it should be taken if applicable
Why is this information important?
The medication dose, route, and name should be compared with the order a minimum of three times. This information is in the EHR if your facility enters orders correctly, so it should be easy to find. Typically this is done when a medication is first removed from medication storage, when it’s being prepared, and immediately before giving it to the patient or before returning the original container to the medication storage area.
Additionally, the 6-8 Medication Rights (the number of “rights” depends on your school’s teaching method) include the following, which can all be found on the original order: right patient, right medication, right dose, right route, right time.
Now that you know what to look out for on a medication order, check out this blog on what should be included on a prescription medication bottle.
*This is especially useful if you’re an instructor setting up medications for nursing simulation.*
More posts like this
