Medication Administration Documentation and Reassessment

Key Points

• Documentation after medication administration verifies right documentation and right response.
• Charting must be timely, accurate, and use approved terminology/abbreviations only.
• PRN medication effects require reassessment based on route-specific onset windows.

Equipment

• MAR and patient medical record access
• Approved abbreviation/reference guide per facility policy
• Post-medication assessment tools (pain scale, reaction check, vital signs)
• Provider-notification workflow for adverse events

Procedure Steps

1. Document medication administration immediately after the dose is given.
2. Record essential details: medication name, dose, route, time, and administration site when applicable.
3. Use approved abbreviations only and avoid unsafe symbols or ambiguous shorthand.
4. For PRN medications, chart the indication for administration clearly.
5. Perform post-administration reassessment according to route/onset guidance.
6. For oral pain medication, reassess pain about 30 to 60 minutes after administration.
7. For IV pain medication, reassess pain about 10 to 15 minutes after administration.
8. Document objective response findings and patient-reported outcomes.
9. If adverse reaction occurs, document event details, provider notification, and follow-up orders.
10. Confirm that charting supports continuity, safety, and legal record standards.

Common Errors

• Delayed charting → omission, duplicate-dose, and continuity risk.
• Using unapproved symbols/abbreviations → misinterpretation and medication error risk.
• Missing PRN indication and reassessment → inability to evaluate treatment effectiveness.
• Incomplete adverse-event documentation → delayed escalation and legal vulnerability.

Related

• oral-medication-administration-safety - Requires route-specific reassessment and timely charting.
• intravenous-medication-administration-safety - Highlights faster-onset routes that need earlier reassessment windows.