SoapLab - Clinical Documentation Training

Medication Documentation Importance

Medication errors are a leading cause of preventable patient harm. Accurate medication documentation — including reconciliation, administration, and prescribing — is essential for patient safety. Every medication interaction with a patient should be documented completely.

Medication Reconciliation

Medication reconciliation compares the patient's current medications against new orders at every transition of care. **When to reconcile:** • Admission • Transfer between units • Discharge • Outpatient visits **What to document:** • All current medications (including OTC, herbals, supplements) • Dose, route, frequency for each • Last dose taken • Allergies and reactions • Medications being continued, held, or discontinued • New medications being started

📋 Complete Medication Entry

**Complete documentation:**
Metoprolol succinate 50mg PO daily — last dose this morning, continue

**Incomplete documentation:**
Metoprolol — taking

The complete entry includes drug name, dose, route, frequency, and action. The incomplete entry is dangerous — which metoprolol? What dose? How often?

The Five Rights

Document verification of the five rights:

•Right patient — verified by two identifiers
•Right medication — verified against order
•Right dose — calculated and verified
•Right route — appropriate for medication and patient
•Right time — given within acceptable window

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High-Alert Medications

High-alert medications require extra documentation: **Examples:** Insulin, anticoagulants, opioids, chemotherapy, concentrated electrolytes **Document:** • Independent double-check performed • Who verified • Patient weight (for weight-based dosing) • Indication for use • Monitoring parameters • Patient/family education provided

Allergy Documentation

Document allergies completely: **Required elements:** • Allergen (specific drug name, not class) • Reaction type (anaphylaxis, rash, GI upset, etc.) • Severity • When it occurred • How it was treated **Example:** ✓ Penicillin — anaphylaxis (throat swelling, hypotension) 2019, required epinephrine ✗ Penicillin — allergy

PRN Medication Documentation

PRN medications require additional documentation:

•Indication for giving (pain level, symptom present)
•Time given
•Dose given
•Route
•Effectiveness assessment (with time)
•Any adverse effects
•Follow-up interventions if ineffective

📋 PRN Documentation Example

**1400**: Patient reports pain 7/10, right knee, aching. Morphine 4mg IV given per order.
**1430**: Pain reassessed — now 3/10. Patient comfortable, no adverse effects. Continues to rest.

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Controlled Substance Documentation

Controlled substances require meticulous documentation: • Waste must be witnessed and co-signed • Document exact amount given and wasted • Count discrepancies must be reported immediately • Document patient response and effectiveness • Be alert for signs of diversion • Document any concerns about misuse

Medication Errors

If a medication error occurs, document: • What happened (factually, no blame) • Time discovered • Patient assessment after error • Interventions taken • Provider notification (who, when) • Patient/family notification • Incident report filed Do NOT document "incident report filed" in the medical record — just document the clinical facts.

Medication Documentation & Reconciliation

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