D.C. Mun. Regs. tit. 17, r. 17-6105

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 17-6105 - RECORD KEEPING

6105.1

The licensed nurse or trained medication employee shall document in the Medication Administration Record ("MAR") medications that have been administered to the program participant and whether the medications ordered have been taken as ordered.

6105.2

A program participant's MAR shall be on file at all facilities where the program participant receives medication.

6105.3

The MAR shall include the following regarding the program participant:

(a) The name of the program participant;

(b) The date of birth of the program participant;

(c) The name of the program;

(d) The month, day, and year the medication is prescribed for administration to the program participant;

(e) The primary and secondary diagnosis of the program participant;

(f) Any known allergies of the program participant, or that the program participant has no known allergies;

(g) The diet order for the program participant;

(h) The name and phone number of the licensed practitioner under whose care the program participant has been placed; and

(i) The name of the supervisory registered nurse responsible for both the review and preparation of the MAR, and the supervision, monitoring and delegation of nursing functions with respect to the program participant.

6105.4

The following information shall be recorded in the MAR for all medications ordered for the program participant:

(a) The name, strength, and frequency of the medication;

(b) The prescribed dosage of medication;

(c) The route of medication administration;

(d) The date the medication is prescribed by the licensed practitioner;

(e) The date and time the medication is to begin;

(f) The date the medication is to be continued if specified by the licensed practitioner;

(g) Indications for the medication; and

(h) Any known allergies.

6105.5

All information shall be recorded on the MAR in permanent blue or black ink. All errors shall be appropriately corrected and there shall be no erasures or whiteouts.

6105.6

All medication information shall be entered on the MAR before storing the medication, and all information on the MAR shall be consistent with the information on the pharmacy label and the order sheet of the licensed practitioner.

6105.7

Immediately after administration of a medication, the trained medication employee shall initial the correct block on the MAR indicating the date and time that the medication was administered.

6105.8

All medication errors and omissions, and any related actions that have been taken, shall be recorded on the MAR by the trained medication employee and reported to the licensed nurse.

6105.9

Each trained medication employee shall enter his or her full name and initials on the back of the MAR the first time each month that medication is administered.

6105.10

The MAR shall be reviewed and signed by a registered nurse at least once each month.

6105.11

When a new medication is ordered for a program participant the licensed nurse shall be notified before the administration of the medication and a photocopy of the prescription shall be placed in the MAR.

D.C. Mun. Regs. tit. 17, r. 17-6105

As amended by Final Rulemaking published at 48 DCR 2581 (March 23, 2001); as amended by Emergency Rulemaking published at 50 DCR 3071 (April 18, 2003) [EXPIRED]; as amended by Final Rulemaking published at 50 DCR 6464 (August 8, 2003) [EXPIRED]; as amended by Final Rulemaking published at 50 DCR 9242 (October 31, 2003)