Senior care

Medication orders and the medication pass

An order is entered, checked by a second person, then given and charted dose by dose.

Needs the Senior care (Healthcare) plan.

Steps

1. Enter the order under Medications. It waits for review, and a second person verifies it before it becomes active (a facility setting).
2. An active order is never edited. A change is a new order that replaces the old one; stopping one needs a reason.
3. At the medication pass, confirm the resident, then chart each dose as given, held, refused, not available or resident away.
4. A dose given outside its time window is marked late or early. A wrong entry is voided with a reason, never deleted.
5. Controlled substances ask for a count, your signing PIN and a witness.