Documenting Medications

Course Code: REL-PAC-0-DMEDS

Hours: 1

Type: Online Course

Content Expiration Date: 12/31/2026

Learning Objectives:
Define your role in medication administration and documentation.
Describe medication administration records and medication logs.
Summarize best practices for documenting the administration of medications and their storage, disposal, donation, and destruction.

Outline:
Section 1: Introduction

About This Course

Learning Objectives

Section 2: Medication Records

Your Role

Medication Documentation Overview

Written Resident Records

Electronic Health Record

Medication Service

Medication Labels

Medication Administration Record (MAR) Components

Medication Log

Review

Summary

Section 3: Documenting Medications

Be Clear and Concise

Special Circumstances

Refusal to Take Medications

Wasted Medications

Controlled Medications

Correct Errors Promptly

Medication Dosing Errors

Meet Suzie

Meet Billy

Summary

Section 4: Best Practices

A Brief Word About Abbreviations

Guidelines for Documentation

PRN Medications

The Rights of Medication Administration

Communicating Your Concerns

Important Questions to Ask

Medication Storage

Medication Disposal

Medication Donation and Destruction

Review

Summary

Section 5: Conclusion

Summary

Course Contributor

References

Congratulations!

Instructor: Jennifer W. Burks, M.S.N., R.N.

Jennifer has over 30 years of clinical and teaching experience, and her areas of expertise are critical care and home health. She is certified as an OASIS Specialist- Clinical (COS-C) and is a Curriculum Designer in post-acute care for Relias. She earned her Bachelor of Science in Nursing from The University of Virginia in 1993 and her Master of Science in Nursing from The University of North Carolina, Greensboro in 1996. Her professional practice in education is guided by a philosophy borrowed from Florence Nightingale’s Notes on Nursing, “I do not pretend to teach her how, I ask her to teach herself, and for this purpose, I venture to give her some hints.”

Relias Learning will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.

Relias Learning has a grievance policy in place to facilitate reports of dissatisfaction. Relias Learning will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias Learning at support@reliaslearning.com.

Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.