Minnesota Requirements for Documentation of Medication
Pursuant to Minnesota Statute 144A.4792 MEDICATION MANAGEMENT, Subd. 8., documentation of administration of medication, each medication administered by comprehensive home care provider staff must be documented in the client’s record. The documentation must include the signature and title of the person who administered the medication. The documentation must include the medication name, dosage, date and time administered, and method and route of administration. The staff must document the reason why medication administration was not completed as prescribed and document any follow-up procedures that were provided to meet the client’s needs when medication was not administered as prescribed and in compliance with the client’s medication management plan.
Subd. 9. Documentation of medication setup. Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.
Subd. 10. Medication management for clients who will be away from home. (a) A home care provider who is providing medication management services to the client and controls the client’s access to the medications must develop and implement policies and procedures for giving accurate and current medications to clients for planned or unplanned times away from home according to the client’s individualized medication management plan. The policy and procedures must state that:
(1) for planned time away, the medications must be obtained from the pharmacy or set up by the registered nurse according to appropriate state and federal laws and nursing standards of practice;
(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall give the client or client’s representative medications in amounts and dosages needed for the length of the anticipated absence, not to exceed 120 hours;
(3) the client or client’s representative must be provided written information on medications, including any special instructions for administering or handling the medications, including controlled substances;
(4) the medications must be placed in a medication container or containers appropriate to the provider’s medication system and must be labeled with the client’s name and the dates and times that the medications are scheduled; and
(5) the client or client’s representative must be provided in writing the home care provider’s name and information on how to contact the home care provider.
(b) For unplanned time away when the licensed nurse is not available, the registered nurse may delegate this task to unlicensed personnel if:
(1) the registered nurse has trained the unlicensed staff and determined the unlicensed staff is competent to follow the procedures for giving medications to clients; and
(2) the registered nurse has developed written procedures for the unlicensed personnel, including any special instructions or procedures regarding controlled substances that are prescribed for the client. The procedures must address:
(i) the type of container or containers to be used for the medications appropriate to the provider’s medication system;
(ii) how the container or containers must be labeled;
(iii) the written information about the medications to be given to the client or client’s representative;
(iv) how the unlicensed staff must document in the client’s record that medications have been given to the client or the client’s representative, including documenting the date the medications were given to the client or the client’s representative and who received the medications, the person who gave the medications to the client, the number of medications that were given to the client, and other required information;
(v) how the registered nurse shall be notified that medications have been given to the client or client’s representative and whether the registered nurse needs to be contacted before the medications are given to the client or the client’s representative; and
(vi) a review by the registered nurse of the completion of this task to verify that this task was completed accurately by the unlicensed personnel.
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