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1. Controlled-substance form: nurse can verify controlled substances at each change of shift. Monitor the receipts, administration, and disposal of a controlled substance.
2. Medication administration record (MAR). It document medication administered to a patient. It includes drug, dose, route of administration, frequency of administration, and the administration time. MAR lists patient's allergies and diagnoses. Yes, every time medication is administered to a patient , you need to update MAR.
3. Medication delivery record: provides accountability (held responsibility) for medication distribution between the pharmacy and hospital or LTF. It lists the medication found in a particular delivery for a patient.
4. Omnibus Budget Reconciliation Act 1990 is the law that require patient profile to be maintained. A patient profile identifies the patient by name, SSN, birth date, and gender. It provides billing information such as insurance (group number, patient's identification, patient's relationship to the cardholder), patient's medical history (current conditions), known allergies, and adverse reactions, listing of all medications (legend or OTC), the medication should have date, quantity, directions for use, and physician's name. list whether patient wants easy-open containers or use generic.
5. Physician order sheet (POS): List all physician's medication orders for a patients. Nondrug orders may include allergies, diagnoses, diet orders, directives, lab orders, and order for ancillary services (physical therapy, occupational therapy, respiratory therapy, speech therapy).
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