Medication Orders & Documentation Flashcards
(13 cards)
1
Q
Stat Orders
A
orders for medication to be administered immediately
2
Q
Authorized Providers
A
- Physician
- Physician Assistant (PA)
- Clinical Pharmacist
- Advanced practice registered nurse (APRN) / Nurse Practitioner (NP)
- Dentist
- Optometrist
3
Q
Prescription
A
Filled at a pharmacy & given to the person who will use it
4
Q
Medication Order
A
used in a facility to dispense medication to a specific patient or resident
5
Q
Verbal Medication Orders
A
Licensed individuals who are authorized to receive verbal med orders:
- RN
- LPN
- LVN
- Pharmacists
6
Q
Normal Ranges
A
Temp: 97.6 - 99.6
Pulse: 60-100
Respirations: 12-20 bpm (breath)
Blood Pressure: 110/60 - 140/90
O2 Sta - > 90% (Greater than)
7
Q
Medication Administration Record (MAR)
A
- All medication administered to residents are recorded on this document
- Has medical History
- Permanent part of a resident’s medical record
8
Q
eMAR
A
- electronic version of the MAR
- electronic health records avoid problems such as illegible handwriting
9
Q
What Information is Documented on the MAR
A
- every time a medicine is administered it must be documented
- if resident refuses medication, it must be documented
- never document before medication is administered
10
Q
Objective Information
A
- Are signs
- Based on what a person sees, hears, touches, & smells (ex. can smell if resident has C. Diff)
- collected by using the senses
11
Q
Subjective Information
A
- something a person cannot or did not observe, but is based on something that the resident reported & may or may not be true
- symptoms
(ex. Resident says medication makes them sleepy)
12
Q
Hypertensive Emergency
A
- BP over 180/120
- systolic BP greater than 180mm Hg or diastolic BP greater than 120mm Hg
- Left untreated can lead to organ failure & death
13
Q
Anaphylactic Reaction
A
- LIFE THREATENING allergic reaction to medication, most likely from antibiotics
- swelling of throat, itchy eyes, trouble breathing
