§ 6400.166. Medication record.
(a) A medication record shall be kept, including the following for each individual for whom a prescription medication is administered:
(1) Individual’s name.
(2) Name of the prescriber.
(3) Drug allergies.
(4) Name of medication.
(5) Strength of medication.
(6) Dosage form.
(7) Dose of medication.
(8) Route of administration.
(9) Frequency of administration.
(10) Administration times.
(11) Diagnosis or purpose for the medication, including pro re nata.
(12) Date and time of medication administration.
(13) Name and initials of the person administering the medication.
(14) Duration of treatment, if applicable.
(15) Special precautions, if applicable.
(16) Side effects of the medication, if applicable.
(b) The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.
(c) If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.
(d) The directions of the prescriber shall be followed.
Authority The provisions of this § 6400.166 amended under sections 201(2), 403(b), 403.1(a) and (b), 911 and 1021 of the Human Services Code (62 P.S. § § 201(2), 403(b), 403.1(a) and (b), 911 and 1021); and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)).
Source The provisions of this § 6400.166 adopted August 9, 1991, effective November 8, 1991, 21 Pa.B. 3595; amended October 4, 2019, effective in 120 days, 49 Pa.B. 5777. Immediately preceding text appears at serial page (381971).
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