Which information is recorded in the medication administration record after a drug is given?
Correct answer: B. The drug, dose, route, time and nurse’s initials
- A. The patient’s response and discharge plan
- B. The drug, dose, route, time and nurse’s initials
- C. The patient’s diagnosis and dietary preference
- D. The prescriber’s full progress note and treatment goals
Explanation
The medication administration record confirms what medication was given, in which dose and route, at what time, and by whom. A patient response may be documented in a progress note, but it does not replace the medication record.
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About Documentation, Reporting and Communication
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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