Accurately record the medication’s name, dosage, and route of administration (IV). Note the time of administration. Include the patient’s identification information, ensuring accuracy.
Document the infusion rate. Specify the dilution method used, if any, along with the diluent’s name and volume. This ensures reproducibility.
Detail any patient-specific instructions received from the prescribing physician, including any special considerations for monitoring. Record any observed adverse effects during or after administration.
Chart the patient’s response to the medication. Describe any changes in symptoms, noting both positive and negative outcomes. This aids in future treatment decisions.
Sign and date your entry using your full name and credentials. This confirms the record’s legitimacy. Follow your institution’s guidelines for electronic health record (EHR) documentation.
Maintain confidentiality according to HIPAA regulations. This is paramount to patient privacy.
