How should a nurse document medication administration?

The correct approach to documenting medication administration involves recording comprehensive details to ensure clarity and accountability in patient care. This includes the date, time, dose, route, medication name, and the patient's response to the medication. Documenting these elements is crucial for several reasons:

1. Patient Safety: Recording the medication name, dose, and route helps prevent medication errors and ensures that other healthcare providers have access to accurate information regarding what was administered.

2. Legal Documentation: Thorough documentation serves as a legal record that the nurse administered the medication as prescribed, which can be critical in case of disputes or adverse events.

3. Continuity of Care: By noting the patient's response, healthcare providers who care for the patient later can assess the effectiveness of the medication and determine any necessary adjustments to the treatment plan.

Overall, this comprehensive documentation creates a clear and accountable record of the patient's medication history, which is vital for safe and effective healthcare delivery.