Ala. Admin. Code r. 610-X-14-.15
Current through Register Vol. 43, No. 1, October 31, 2024
Section 610-X-14-.15 - Documentation Standards(1) The standards for documentation of medication assistants, certified provided to patients by MACs are based on principles of documentation, regardless of the documentation format.(2) Documentation of nursing care shall be:(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, responses, treatments, medications, communication of pertinent information to other health team members, and unusual occurrences involving the patient. A signature of the writer, whether electronic or written, is required in order for the documentation to be considered complete.(d) Timely. 1. Charted at the time or after the care, to include medications. Charting prior to care being provided, including medications, violates principles of documentation.2. Documentation of medications given that is not in the sequence of the time the care was provided shall be recorded as a "late entry," including a date and time the late entry was made, as well as the date and time the care was provided.(e) A mistaken entry in the record by a MAC shall be corrected by a method that does not obliterate, white-out, or destroy the entry.(f) Corrections to a record by a MAC shall include the name or initials of the individual making the correction.Ala. Admin. Code r. 610-X-14-.15
Adopted by Alabama Administrative Monthly Volume XXXIX, Issue No. 12, September 30, 2021, eff. 11/14/2021.Author: Alabama Board of Nursing
Statutory Authority:Code of Ala. 1975, § 34-21-2.1.