Download PATIENT CARE - Policy 39 - MEDICATION ADMINISTRATION

HERTFORD-GATES HOME HEALTH
SUBJECT: MEDICATION
ADMINISTRATION
SECTION:
POLICY:
EFFECTIVE DATE:
REVISIED DATE:
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POLICY
Medications are administered in accordance with the agency's policies and procedures, accepted
standards of practice and under a physician's order.
PURPOSE
To ensure competent and safe medication administration to patients.
PROCEDURE
1. A physician's order is obtained for all medications to be administered by the home health
agency staff.
a. Verbal or telephone orders are immediately reduced to writing and countersigned by
the physician within fourteen days.
b. Home health nurses obtain orders for any changes in the patient's medication regimen
whenever the nurse will be required to administer the medication or instruct the
patient/caregiver regarding a change in dosage, route of administration, etc.
c. The physician's order specifies:
1) Patient's name
2) Medication name
3) Medication dose
4) Medication route of administration
5) Frequency of administration
6) Medication start date and time
7) Medication stop date and time
2. All home health patients have a comprehensive assessment of all prescription and over-thecounter medications at the time of admission to identify:
a. Possible ineffective drug therapy or adverse reactions.
b. Significant side effects.
c. Drug allergies.
d. Contraindicated medication.
e. The patient/caregiver's level of knowledge about medications.
HERTFORD-GATES HOME HEALTH
SUBJECT: MEDICATION
ADMINISTRATION
SECTION:
POLICY:
EFFECTIVE DATE:
REVISIED DATE:
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3. The admitting nurse is responsible for documenting all medications on the Plan of Care
(HCFA #485) and on the medication profile.
a. The medication profile is kept current throughout the patient's admission to home
health services.
b. The list of medications on the HCFA #485 is updated at least every 60-62 days.
4. The nurse is responsible for instructing the patient and/or caregiver on the following using
using the computerized medication information sheets:
a. Medication schedule and the importance of compliance.
b. Effects and desired actions for all medications.
c. Interactions, side effects and adverse reactions to be reported.
5. Medications are only administered by individuals holding a current license or permit in North
Carolina as a registered nurse or licensed practical nurse.
6. Individuals administering medications are responsible for knowledge of specific medication:
a. Action
b. Indications
c. Side effects
d. Special precautions
e. Contraindications
f. Usual dose
g. Route of administration
7. Home health care licensed registered nursing staff may administer all medications except the
following:
a.
b.
c.
d.
e.
f.
g.
h
I.V. Blood Products
I.V. Pitocin
I.V. cardiac drugs
I.V. Aminophylline
I.V. Barbiturates
I.V. Calcium
I.V. Phenothiazine derivatives
I.V. Central nervous system depressants
HERTFORD-GATES HOME HEALTH
SUBJECT: MEDICATION
ADMINISTRATION
SECTION:
POLICY:
EFFECTIVE DATE:
REVISIED DATE:
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PATIENT CARE
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8/9/95
i. I.V. Mercurial derivatives
j. I.V. Thrombocytic enzymes
8. Home care licensed practical nurses may administer all medications except the following:
a. I.V. Medications
b. Parenteral anticoagulants
c. Parenteral cardiac drugs
9. Licensed home health nursing staff may administer medication through the following routes of
administration:
a. PO
b. IM
c. Sub-Q
d. Ophthalmic
e. Topical
f. Otic
g. Per rectum
h. Vagina
i. Nasal
j. Refer to specific infusion nursing policies and procedures for approved activities
involving peripheral and central intravenous lines, intrathecal, epidural, and implanted
devices.
10. All nursing staff are required to adhere to the following steps when administering
medications:
a. Verify the physician's order for medication administration.
b. Verify date and time of last medication administration by checking documentation in
the patient's medical record.
c. Research unfamiliar medications to determine actions, indications, side effects, special
precautions, contraindications, usual dose, and route of administration.
d. Wash hands.
e. Note any food or medication allergies.
f. Check medication container label against transcribed medication order for patient's
name;
HERTFORD-GATES HOME HEALTH
SUBJECT: MEDICATION
ADMINISTRATION
SECTION:
POLICY:
EFFECTIVE DATE:
REVISIED DATE:
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PATIENT CARE
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medication name, dose, and route; and frequency of medication administration.
g. Check medication for product stability and refrain from using:
1) any substances from inadequately labeled containers.
2) cloudy I.V. solutions.
3) Solutions having precipitates.
4) Expired medications.
h. Check container label again for accurate medication,
i. Dispense medication dose:
1) without touching medication.
2) Measuring liquids with liquid poured to the meniscus level and checked at eye level.
3) verifying dose calculations as necessary.
j. Check container label again for accurate medication.
k. Explain to patient what you are about to do, and give an opportunity for the patient's
implied consent.
l. Recheck before proceeding with medication administration if the patient questions any
aspect of the procedure.
m. Administer medications according to agency policies and procedures on medications.
n. Document medication administration by charting in the patient's medical record:
1) medication name
2) medication dose
3) medication route of administration
4) administration site, as appropriate
5) date and time of medication administration
6) patient's reaction to medication administration
7) nurse's name and professional designation
11. Notify the physician immediately of:
HERTFORD-GATES HOME HEALTH
SUBJECT: MEDICATION
ADMINISTRATION
SECTION:
POLICY:
EFFECTIVE DATE:
REVISIED DATE:
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a. any signs and symptoms of adverse reaction toxicity.
b. medication is held or omitted for any reason.
c. any medication error. (Refer to Medication Error Policy)
12. Home health agency staff members will not transport or dispose of any medications in the
home.