Electronic Medication Administration Record Summary

information is loaded into the individual’s medical record to provide an ongoing record of the

Assess patient’s environment like bed side rails, call lights within patient reach, allergic bands among other interventions established by the hospital as arm bands before administrating medication plus incorporating the using the barcode scanning system.

The intended use of medications is meant to improve a person’ health, it is very important the individual administering medication or self-medicating use the drugs correctly, by following the doctors’ instruction for the medication prescribed. Medication is given to diagnose, treat, and prevent illness. Medication can be very dangerous, which can potentially cause harm or even deaf if it’s not used properly.

rights, health, and safety of the patient.” This provision, identifying patients, medication safety are related because it is a nurse’s responsibility to protect the patient from harm and promote safety. Nurses are taught to use multiple checks before administering a drug and use two identifiers. These checks include checking the medication against the order when obtaining it, checking again when preparing the medication and the last check is done at the patient’s bedside prior to giving the medication. Also it is imperative to question any medication order that does not seem fit. The order should include a date, time, name of the medication, dosage strength, the route for

It is imperative that all members of the care team are able to quickly and accurately communicate the patients’ condition and needs to other members of the care team. Proper communication allows for better monitoring of the patients’ condition and allows the providers and pharmacists to more accurately assess the patients’ treatment needs. The implementation of electronic medical records (EMR), as Nightingale Hospital is currently researching, has been shown to greatly improve care team communication and patient outcomes by allowing easy, verifiable access to all the patients’ records. Implementation of an EMR system will provide a necessary foundation for a great improvement in staff and provider communication, resulting in improved outcomes for all patients, including those undergoing anticoagulation therapy. Specifically regarding anticoagulation therapy, EMR will allow other care team members, including other nurses, providers and pharmacists’ one place to look for patient histories, allergies, lab and other results and monitor, potential drug interactions and adjust medication levels with regard to patient specific needs. EMR will also allow for more accurate medication administration through

When patients are brought back for rooming, the nurse or medical office assistant will review the printed list with the patient prior to documenting in the EMR. During the office visit, we will review polypharmacy and are adding a document to our resources section of the EMR regarding polypharmacy and accurate medication list that will be given to all patients. I have always been aware of the importance of accurate medication list, but was not reviewing this often enough in our patients EMR.

These systems will also help cut down on medication errors by comparing the patient’s to medications or interventions so that it is given to the correct patient. Also documents the care given so there would be no human error in the case of questioning whether care had been given as long as the caregiver documents in the record. These features of the electronic health record are in place to promote patient safety by reducing errors.

The nurse must verify the physician’s medication order, including the dose and time, and then the pharmacy is responsible for their own checks and balances via the BCMA system in order to complete the dispensing phase of the medication (Gooder, 2011). The nurse enters the BCMA system with a login and password and is able then to see a list of the virtual due list for a specific patient. The computer on wheels is then taken to that patient’s room and the five rights of medication administration begin. As nurses, we are taught to use the five rights of drug administration are (1) right patient (2) right medication (3) right dose (4) right route and (5) right time. By scanning the barcode on the patient’s hospital identification band, the nurse then asks for the patient to verbally state their name and date of birth, which can be verified by the nurse on the virtual due list and then choses the medication that are due for administration at that time. The medication is dispensed and the nurse is able to scan the barcode on the medication, the scanning triggers the automatic documentation of the medication given (Kelly, 2012).

The nurse uses a keyboard, mouse, screen, and computer to access the patient’s medication administration record (MAR) stored in the CPRS.

            As electronic health records, have been a former nursing present transition, medication list equally compare in a transition as medication reconciliation is addressing preexisting medications that are no longer being taken by the patient, removed from the patient's medication list. The development of medication reconciliation is becoming the up and coming push to obtaining patient medication list accurately, precisely, and safely beginning in outpatient settings.  Similarly, nursing presences theory supports direct nursing practice to improve direct patient care, safety among medication treatment, as well as engagement to providers with patients (Presence in nursing practice: a concept analysis,

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

NH Board of Pharmacy has oversight over the Prescription Drug Monitoring Program in New Hampshire and the aforementioned annual report is posted on the Board of Pharmacy, Prescription Drug Monitoring Program webpage5 in Adobe Portable Document Format (PDF). The report is located on the webpage under the ‘General Information’ section.

In one study, Baxter International reported that nurse’s cause 38% of medication errors during administration. After implementing eMar, it showed a dramatic 89 % decrease in medication errors. With the application of technology in the clinical setting it allows communication among healthcare professional in achieving efficient and a world-class service to the patient.

If the physician prescribe an e-script for morphine 30mg two tablets by mouth three times per day, an alert informed the prescriber there is no option for refill because it is a control substance schedule 2 medication. A default check in the box allows the prescriber to review the e-prescription before submitting. The computer then generate an image of the e-prescription with the physician’s signature, the DEA number and provider indicator. The Physician insert the encryptn key (size of a flash drive) in the computer, enter the password to log in the system and pin number. This is known as the secondary factor authentication. The physician clicks send in real time and wait. Three pieces of information must be known: identification of prescriber, e-prescription vendor and the network (DEA data base). The e-prescription is submitted to the pharmacy and confirmation of the script is faxed to the pharmacy. The pharmacist calls the prescriber in real-time to confirm the e-prescription submitted at 10:16am; faxed confirmation received at 10:17am; and e-prescription received at

Electronic medical records had a great impact in the ushering in of the age of Nursing Informatics. (Himss, 2010)EMRS present healthcare professionals with the ability to retrieve and organize data in a quick and efficient approach. With information so readily available, patient safety increases and we know that patient cost goes down. This happens because patient medications, allergies, history, demographic, and treatment information is more collectively available.