Medical Assistant Prep / Unit 6 MAS 145 review, 2 to 3 minutes
Recording What Was Given
The idea
This example is constructed for this course. It walks through what a medication record captures after a medication is given, why each part of the record matters, and when it must be written.
In practice
After giving an injection that the provider ordered and that she is trained and permitted to give, a medical assistant records it before doing anything else. She records the drug's name, the amount given and the route. She records the time, in twenty-four-hour form if the practice uses it, so that fourteen thirty cannot be mistaken for two thirty in the morning. Where the practice's procedure calls for it, she records the injection site, along with any lot number and expiration date the procedure requires. Finally she records her own name, and she notes how the patient responded, because watching the response is one of the expanded rights. A colleague who opens the record an hour later can now see exactly what was given, when, where, and by whom. That information prevents a second injection by someone who did not know about the first, and it tells the provider what to look for if the patient feels unwell later.
Where people slip
Record right away, not at the end of the day. A medication given but not yet recorded is invisible to everyone else in the practice, and that invisibility is how double doses happen. If you are interrupted, finish the record before you start the next task. And if you discover that something was left out of a record, follow the practice's procedure for adding a late entry rather than squeezing it in unmarked, a rule that unit twenty-eight explains in full.
Your place on the trail
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