MEDICATION ADMINISTRATION RECORD

Month and year: [Month, year]
Setting: [Facility or home name, unit, room or bed]
Page: [Page number] of [Total pages]

RESIDENT OR PATIENT
Name: [Full name]
Date of birth: [Date]
Photo on file: [Yes, with the date taken, or no]
Diagnoses: [Conditions the medications treat]
Allergies: [Drugs, foods, and latex, with the reaction, or no known allergies]
Weight: [Weight and the date measured]
How they take medicines: [Whole, crushed, liquid, in applesauce, or with water; any swallowing concerns]
Prescriber: [Name and phone]
Pharmacy: [Name, phone, packaging, and cycle start date]

SCHEDULED MEDICATIONS
Copy this block for each medication.

Medication: [Name, strength, and form]
Dose and route: [How much, and how it's given, such as 1 tablet by mouth]
Frequency and times: [How often, and each time it's due]
Reason: [What it's for]
Start date: [Date]
Stop date: [Date, or ongoing]
Special instructions: [Checks before giving, hold parameters such as a pulse or blood pressure limit, with or without food, may crush or don't crush]
Grid, one line per time it's due, with initials or a code in each day:
[Time]: [Day 1] [Day 2] [Day 3] [Day 4] [Day 5] [Day 6] [Day 7] and on through [Day 31]
[Time]: [Day 1] [Day 2] [Day 3] [Day 4] [Day 5] [Day 6] [Day 7] and on through [Day 31]
Readings: [Pulse, blood pressure, or blood sugar, written in the box when the order needs a check]

CODES FOR DOSES NOT GIVEN
Write the code in the box, then a note below.
R: Refused
H: Held, for a hold parameter or the prescriber's instruction
A: Away, on leave or at a program
V: Vomited after the dose
N: Not available
O: Other, explained in the note
Note for each code: [Date, time, medication, code, reason, what you did, who you told, initials]

PRN MEDICATIONS
Medication: [Name, strength, and form]
Dose and route: [How much, and how it's given]
Reason to give: [The reason in the order, such as pain or a seizure lasting 5 minutes]
Minimum time between doses: [Hours]
Maximum in 24 hours: [Number of doses or total amount]
Protocol: [Seizure, allergy, or other action plan; when to repeat; when to call 911; who is trained to give it]
Each dose: [Date and time] · Reason and assessment: [Symptom, score, or seizure timing] · Dose: [Amount] · Given by: [Initials] · Effect: [Result, time checked, initials]

CONTROLLED DRUG COUNT
Where the law or your organization requires one.
Medication: [Name, strength, and form]
Count: [Date and time] · On hand: [Number] · Counted by: [Two signatures]
Received, used, or wasted: [Amount, reason, and witness]
Signed out and back in: [For leave or a program: amount, who took it, and when it came back]
Discrepancy: [What didn't match, who was told, and the outcome]

SIGNATURE AND INITIALS KEY
[Initials]: [Printed name, role, and signature]
[Initials]: [Printed name, role, and signature]

MONTHLY REVIEW
New month checked against current orders: [Date, and the two people who checked]
Changes this month: [Medications started, changed, or stopped, with the date and prescriber]
Medication review: [Date of the last prescriber or pharmacist review, recommendations, and the next one due]