N.H. Admin. Code § He-M 1202.06

Current through Register No. 50, December 12, 2024

Section He-M 1202.06 - Documentation

(a) For each individual for whom medications are administered, an authorized provider shall maintain in the individual's record documentation of medication administration in accordance with applicable provisions of He-M 408.07 including the following:

(1) The name of the individual;

(2) Medication order sheets or progress notes shall specify, at a minimum:

a. The individual's allergies;

b. Medication name;

c. Medication dosage;

d. Route of medication administration;

e. Medication frequency;

f. The date and time of administration; and

g. Special considerations in taking the medication, if applicable, as directed by the prescribing practitioner or the pharmacist.

(b) The authorized provider shall document each instance of medication administration in the MAR at the time that a medication is administered, including his or her full signature, credentials, and initials in a section designated for such purpose.

(c) When a PRN medication is administered, documentation in the MAR shall include the reason for administration and the medication's effectiveness.

(d) When a controlled drug is prescribed for an individual, the authorized provider shall maintain an inventory that includes:

(1) The name of the individual;

(2) The name of the prescribing practitioner;

(3) The name of the drug and strength;

(4) The amount used;

(5) Amount remaining;

(6) The time and date administered;

(7) The name and credentials of the person who administered the medication;

(8) Documentation of a daily count; and

(9) If applicable, documentation of disposal in the presence of 2 people, at least one of whom is a licensed person, as defined in He-M 1202.02(p) .

(e) An authorized provider shall document in the MAR:

(1) Each medication error upon discovery; and

(2) An individual's refusal to take medications.

(f) Documentation required pursuant to (e) above shall, at a minimum, include the following:

(1) The individual's name;

(2) The date and time of the medication error or refusal;

(3) The drug name, dosage, frequency, route of administration, and prescribing practitioner;

(4) A description of the medication error or refusal;

(5) The date and time of notification of a licensed person, pursuant to He-M 1202.03(q) or (r) ;

(6) Actions recommended by the licensed person;

(7) Actions taken by the authorized provider; and

(8) The date and time of notification of a nurse trainer.

(g) Changes in medication orders shall be:

(1) Documented on the MAR by licensed persons or authorized providers; and

(2) Reported to the nurse trainer.

(h) The authorized provider shall document, in the MAR, any medication withheld and the reason(s) the medication was withheld.

(i) The requirements of (a) -(g) above shall not apply to individuals who self-administer medication pursuant to He-M 1202.04(a) .

N.H. Admin. Code § He-M 1202.06

#7957, eff 9-19-03; ss by #9978, INTERIM, eff 9-19-11, EXPIRES: 3-19-12

Amended by Volume XXXVII Number 23, Filed June 8, 2017, Proposed by #12192, Effective 5/26/2017, Expires 5/26/2027.