Medication Documentation for California

Course Code: REL-PAC-0-MDC

Hours: 1

Type: Online Course

Content Expiration Date: 12/31/2025

Learning Objectives:
Identify your role in the documentation of medication administration and self-administration in California residential care facilities.
Explain the different types of medication orders.
Describe medication administration records and medication logs and how to use them.
Apply 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 and Orders

Your Role

Definition

Routine Orders

PRN Orders

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

Summary

Section 4: Best Practices

A Brief Word About Abbreviations

The Rights of Medication Administration

Medication Storage

Medication Disposal

Medication Donation and Destruction

Review

Summary

Section 5: Conclusion

Summary

Course Contributor

Resources

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.”

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All courses offered by Relias Learning, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.

To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.

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