12.5 Medication Record and Documentation

Documentation

In addition to the documentation in the records/forms, inclusive of electronic systems, the client and team members involved in medication management should have an up- to-date list of all medications the client is taking (including prescription, over-the-counter [OTC], and natural health products).

Medication Record

A Medication Administration Record (MAR) is used by nurses and typically identifies individual medications and dose, including generic and trade name. When nurses administer medication, they are accountable for verifying that each medication administered matches the medication on the MAR, with space to sign each time it is provided to the client.

Health Care Assistants must have a form or record to document the medication(s) they assisted with, at the specified time. As HCAs do not have training in pharmacology, they are not required to know medications by name and are not expected to have detailed knowledge of actions, interactions, contraindications, or indications of medication. By documenting in the medication assistance record provided by the agency, the HCA acknowledges assistance was provided to the client, in accordance with the care plan and/or medication record, at the specified date and time. The care plan and/or medication record provides any additional client-specific instructions, including the level of assistance the client may require.

When an HCA documents on the medication record, a single signature and/or initial is required when assisting with a controlled dosage system that may contain single or multi- dose medication. *See example 1 – blister pack medication.

Each non-controlled dosage medication also requires a signature and/or initial. Non-controlled dosage system medication should identify the name of the medication and additional direction as required such as route and/or specific location to be applied. *See example 2 – eye drops.

Health Care Assistants are not accountable to create, alter, or verify the accuracy of medication records. Medication records must be prepared for use by a regulated health care provider or provided by a pharmacy in a paper record or electronic format.
Example 1 
Example 2 

Additional Medication Documentation Recommendations

The following recommendations promote standardized documentation for effective communication and client safety:

  • Medication times should be identified using the 24-hour clock (e.g., 8:00 p.m. recorded as 2000 hr.).
  • Medication records must be available at the point of care for the HCA to perform required safety checks and “rights.”
  • Assistance with medication shall be documented immediately after assisting a client, at the point of care.
  • Additional documentation is required when the client does not take medications as per the care plan, including the specific reason and follow-up action taken (e.g., client refused morning medication, states “blue pill upsets my stomach,” supervisor M. Nurse, R.N. notified).
  • Documentation is only completed by the health care provider performing the activity and is never done on behalf of another health care provider.
  • Documentation of both the removal and application of transdermal patches.
  • Track the site of application or injection when medications require rotating sites (e.g., transdermal patch, insulin, etc.).
  • When documenting in paper-based systems:
    • use permanent blue or black ink; never write in pencil or use an eraser.
    • initials may be used to sign when the full name, signature, and initials are recorded on an employer maintained master signature record.
    • manage documentation errors according to employer policy, procedure or processes; never use white-out or felt markers to delete entries.
  • completed medication records be retained with the client’s health record in accordance with employer policy and made available to the regulated health care provider accountable for care planning and medication reviews.

Reporting Errors

The RN who delegates the task (at times there may be other RNs covering) is the primary contact person when concerns around the DOT or client arise. The RN coordinates all aspects of the authorized client support and any delegated tasks to be completed. Please note that Social Workers and LPNs are not able to authorize delegated tasks to HCAs. The Supervisor, not an RN is able to assist and support all HCAs in training related to delegated care tasks, but only an RN may authorize the actual delegation. Please ask to speak to a RN when seeking urgent direction around any delegation of task.

Situations when the HCA should report an issue when assisting clients with medications may include:

  • an issue with the Controlled dosage system, such as:
    • wrong name on pack
    • client reports pills or number of pills is very different from what is usually given
    • the pack has been tampered with and there is no explanation documented
    • the medication is not available or is past the expiry date or date range is incorrect
  • a possible medication error, such as:
    • HCA forgot to give medication
    • HCA failed to follow one or more of the critical ‘rights’
    • pill dropped in sink/floor
  • meds from previously scheduled doses found remaining in used blister bubble, such as:
    • meds given to client from incorrect blister pack
    • patch not removed at correct time
  • concerns regarding the client, such as:
    • client is ill
    • client has vomited the medication
    • client is refusing medication
    • signs to observe for on the DOT standard care plan are present
  • changed medication or requests for additional client assistance is not listed on the Care Plan or Medication Record, such as:
    • new time for oral meds to be given
    • new medication in the home
    • request from client/family to assist with medication
  • other situations that arise that may be of concern to the HCA.

Medication errors do occur. If you think that a medication error has occurred by yourself or someone else, you must report this to the supervisor/RN so decisions on next steps can be made. Failing to report a medication error could result in losing your job and/or possible legal action. Reporting errors can help prevent harm to your client. When reporting medication errors, agency policies and procedures may require you to document either in the client’s chart and/or the completion of an incident form.

Summary:

While medicines make a significant contribution to preventing and treating disease, increasing life expectancy, and improving quality of life, they also have the potential to cause harm. The inappropriate or incorrect use of medicines can have an adverse effect on the health of clients. Part of ensuring appropriate use is following instructions, protocols and guidelines. Health Care Assistants must understand their own roles and responsibilities and of those involved in medication administration and follow the instructions, protocols, and guidelines in their role in providing assistance.

Remember:

  • HCAs may only administer medication under the direct supervision of a registered nurse.
  • HCAs must never administer medication unless specifically delegated and trained to do so.
  • HCA must adhere to procedures and agency requirements for assisting with medication.
Review Questions 
  1. Who authorizes the HCA to perform a delegated task?
    1. Family Members
    2. Physician
    3. Registered Nurse (Only a Registered Nurse may delegate a Medication task to an HCA)
  2. What kind of information always needs to be included on the client’s medication label?
    1. Client Name
    2. Pharmacy Name & Phone Number
    3. What route to be given
    4. All of the above
  3. If problems occur pertaining to a medication lockbox in the home, the HCA should call the:
    1. Supervisor
    2. Client’s Family
    3. The last HCA who visited the client
  4. If the HCA has a concern about a delegated task they should discuss the concern with the client or the family.
    1. True
    2. False (The HCA must discuss concerns about a delegated task with the clinician. The Client and family are not the appropriate sources for the HCA to take their concerns to, as they are not responsible for the as they are not responsible for the delegation to the HCA)
  5. An HCA should follow the 6 Critical “RIGHTS” of Medication Administration when,
    1. the client is unfamiliar to you
    2. there has been a change on the DOT Standard Care Plan
    3. every time you assist a client with their medications (The HCA is accountable for ensuring the Right Client, Right Medication, Right Time & Day, Right Route, and Right documentation is followed every time they assist a client with medications)
  6. There are some things that may make the HCA suspicious that the medication in the blister pack they are about to use may be incorrect. What are they?
    1. client states these are the wrong pills
    2. blister pack has been opened or tampered with and no corrective notation on it
    3. names or dates on
    4. all of the above (All of these are indicators that HCA should what they are doing stop and seek direction.
  7. When an HCA documents on the medication record, a single signature and/or initial is required when assisting with a controlled dosage system.
    1. True
    2. False
  8. If you’ve read the DOT Standard Care Plan once, you don’t need to read them on any further visits to the client’s home.
    1. True
    2. False. HCAs must read the HS Service Plan and DOT Standard Care Plan on every visit to the client’s home, as changes to the client’s service may occur at any time without the HCA being aware of them. Checking these documents carefully on every visit ensures safe and accurate care for both the client and HCA)
  9. The following are situations when the HCA should report an issue when assisting clients with medications:
    1. a possible medication error
    2. concerns regarding the client
    3. issue with the Controlled dosage system
    4. All of the above (any or all of these should be reported to the supervisor or nurse).
  10. When meeting a client for the first time, all HCAs must use 2 client identifiers to ensure they have the correct person. Some examples of appropriate identifiers to use are:
    1. Client name
    2. Date of birth
    3. Address
    4. All of above

Unit 12 Attributions and References

Unit 12.3 Image Attributions

  • Figure 12.3.1 Six Rights of Medication by T. Christianson  is licensed under a CC BY 4.0 licence.

Unit 12.4 Image Attributions

References

Interior Health. (2017). Community health worker medication competency program: Home support education. Used with permission from the Director, Home Support Transformation.

Alberta Health Services – Policy, Practice, Access & Case Management Provincial Seniors Health and Continuing Care (2022). Medication assistance program (MAP) manual. https://www.albertahealthservices.ca/assets/info/seniors/if-sen-map-program-in-alberta.pdf

License

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Personal Care Skills for Health Care Assistants Copyright © 2023 by Tracy Christianson and Kimberly Morris, Thompson Rivers University. is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.

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