ieMR Quick Reference Guide Medication Administration · 2020. 10. 14. · ieMR Quick Reference...

ieMR Quick Reference Guide

Medication Administration

MA - Medication Administration Overview, v1.2, MA013, 14/10/2020

Townsville Hospital and Health Service

Contents

Medication Administration Wizard MAW Overview ........................................................ 1

Charting Medication Not Given ........................................................................................ 5

Patient Self-Administered Medications ............................................................................ 7

Patient Self-Administered Medication – No Medication Order ...................................... 7

Modifying a Medication Administration ........................................................................... 7

Un-chart Dose Given ......................................................................................................... 9

Forwarding a Medication Administration for Co-sign (Witness) ................................... 9

Actioning a Co-Sign Witness from Message Centre ..................................................... 11

Supervising Student Nurse Medication Administration ............................................... 12

Medication Administration Wizard MAW Overview

1. During medication preparation, review the MAR (including special instructions, ordercomments, last dose date/time), and perform medication safety checks.

2. At the patient’s bedside, open PowerChart/FirstNet and perform verbal PPID checkand allergy check.

3. Navigate to the MAR.

4. From the toolbar, click the MAW (Medication Administration Wizard)

.

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Medication administration should always occur using the MAW (Medication

Administration Wizard). This allows for barcode scanning of the patient’s wristband

to augment the positive patient ID (PPID) process.

5. Scan the patient wristband using the barcode scanner. If scanning is not possible, click Next. The Override Reason window will open.

6. Select relevant reason for not scanning from the dropdown menu e.g. Unable to Scan Barcode.

Overriding scanning bypasses an important safety check. Failure to correctly

identify the patient may result in a medication being administered to the incorrect

patient. If you override scanning – be aware that the risk of error has increased

significantly, and additional vigilance is required.

7. Relevant medications will display in the Medication Administration window.

The MAW will display all overdue medications, any medications due in the next 75

minutes, PRN medications and any continuous infusions.

8. Select the medication you need to chart by clicking the checkbox to the left of the

medication.

9. A blue tick will appear next to the medication and the dose information will auto-

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populate in the Result column.

If administering multiple medications, you can multi-select the check boxes.

10. Select the Result drop field for each medication to open the Administration Window.

11. Modify/add details within the administration window as required, including Witnessed by name.

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Clinicians should never modify the Performed by field to another user. This is your

digital signature (as you are the person logged into ieMR) and should never be

changed.

If an Enrolled Nurse has administered the medication within their scope of practice, they should be logged into ieMR and their name will appear in the performed by field. If an EN witnesses the administration of medications, then the Registered nurse/midwife must be logged into ieMR, and the RN/RM name displayed in the performed by field. The EN will record their name in the witnessed by field.

12. Once all appropriate medication information has been entered, click OK to finalise.

13. If a nurse witness was entered, the system will prompt for a witness to sign – witness to enter their password and select OK.

14. This will take you back to the MAW. If further medications were to be administered,

complete steps 7 to 12 for each medication.

15. Once medication administration is finalised, select Sign. This is the primary

(logged in) nurse’s signature in the system and completes the medication

administration documentation.

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The action cell will now populate at the administration time/date and will display the dose administered. The administration task will also populate with the ‘last dose’ date and time. This information will appear in the MAR and MAR Summary.

Charting Medication Not Given

To chart medication tasks as Not Given using the MAR follow the steps below:

A Not Given medication refers to a medication that:

Is withheld or unable to be given as per nursing clinical judgement.

Or

A refused medication (see possible reasons in point 4).

A medication withheld by the doctor as a phone/verbal order (not ordered as a

withhold in the MAR) will need to be documented as a Chart Not Done.

1. Navigate to the MAR from the Menu.

2. Click the scheduled administration task you need to chart as not given.

The Medication Administration window will open.

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3. Select the checkbox .

4. Select your reason from the dropdown menu.

5. Add a comment

6. Click the green to sign.

7. Refresh the page.

The result will now display as Not Given with the selected reason

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Patient Self-Administered Medications

Note: All patient self-administered medication administration must be

documented on the MAR to indicate the patient has received a dose.

As the patient has self-administered the medication however, you are not

required to document the administration of the medication via the medication

administration wizard.

1. Double click on the dose from the MAR, and in the medication administration

window change the time to when they actually took the dose.

2. Click on the Comment button – and enter: Patient self-administered, not witnessed

by Nursing Staff

3. Green tick to sign

Patient Self-Administered Medication – No Medication Order

If the patient self-administers a medication that has not been prescribed (not available on

the MAR) you would:

1. Notify the Medical Officer immediately

2. Document the details in progress notes of ieMR

Modifying a Medication Administration

Note: This function is used to modify a medication administration after the initial

administration has been documented (e.g. to add additional detail or amend

incorrect administration details).

1. Right click on the action cell of the administration of medication

2. Select modify

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3. The medication administration window will open – for this example a witness name

will be added to the administration.

4. In the witnessed by section, the witness can enter their novell details.

5. Click on the green tick to sign

6. The witness will then be prompted to enter their password

7. The action cell will update with (C) indicating it has been modified

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Un-chart Dose Given

Note: This function can be used to un-chart a medication administration that

was documented in error.

1. Locate the medication dose on the MAR that was previously documented as given

2. Right Click on the action cell and select Un-chart

3. You will need to enter a reason in the box that pops up, before the system will allow

you to save

4. The action cell will now say *in error, and the dose will then become available again

on the MAR (at the time it was originally charted for). If the dose was previously

overdue, it will reappear on the MAR as a blue tile as the dose has been modified.

Forwarding a Medication Administration for Co-sign (Witness)

In the event the witness field was not entered in at the time of administration and the nurse

witness has since finished his/her shift or is not immediately available, the documentation

can be forwarded for co-signing.

1. Go into the MAR

2. Right click on the administration cell

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3. Select Forward/Refuse from the drop-down menu.

4. A forward box appears

5. From the dropdown menu select Sign.

6. Then click on the binoculars icon to open the address book

7. Type the witness name into the top field

8. Click on the correct name from the list generated

9. Click Add and Ok

10. The clinician can then enter in a comment (i.e. you forgot to co-sign the order, please complete).

11. Then click Ok.

12. When the recipient opens ieMR a message will appear in this Message Centre.

13. The message can be double clicked to record the witness signature against the

event or alternatively the message can be opened. Then by right clicking the nurse

witness can open the patient’s chart, navigate to the MAR and Sign as the nurse

witness.

When a witness signature has been missed, a comment must be documented

against the administration record.

To document right click and select Add comment. Enter a reason why second

witness signature was not entered at time of administration. Select ok.

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EG: Witness called to resus. Message forwarded for co-signature.

Actioning a Co-Sign Witness from Message Centre

1. If you were a witness to the administration of medication, then were called away

and unable to sign in the witnessed by field – the Nurse who administered the

medication will forward the medication administration to you for co-sign.

2. This will appear in your message centre - under results/other

3. If you double click to open the message, it will tell you who sent the co-sign request,

and what the medication administration was. You have the option to either sign; or

refuse in the bottom left action pane.

4. Once you have made your selection, click ok or ok/next if you have more than one.

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Note: All medication administration co-sign requests should be signed as soon

as you receive them – please ensure you are checking your message centre at

least once a shift

Supervising Student Nurse Medication Administration

This QRG is specifically used to support Registered Nurses and Student Nurses with administering medications via the Medication Administration Wizard.

Note to Student Nurses: All medication administration and documentation must

be performed with the Supervising RN.

1. When a Student Nurse is performing the administration of the medication, the

supervising Registered Nurse is required to be logged in to Power Chart.

2. Perform the required PPID checks by verifying the patient and scanning their

wristband

3. Select the tick box next to the medications that are to be administered at this time

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4. Click on the Result column on the right-hand side of the page. The medication

administration window will open

A student nurse MUST NOT document administration of medications via their

own log in. The Supervising Nurse MUST be logged into ieMR and a comment is

added to say the student nurse administered the medications.

The Novell login for the nurse already logged in should pre-populate into the Performed By

field. If a second nurse is required to also witness the administration, they will then be

required to enter their details into the Witnessed By field.

5. A Comment should then be added to reflect the student nurse administered the

medication

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6. Click OK. If entered, the Nurse Witness will then be required to enter their password

7. Click Sign and Refresh

8. Double click on the action cell task line to open the Result Details screen and click

on the Comments tab to review administration details

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ieMR Quick Reference Guide Medication Administration · 2020. 10. 14. · ieMR Quick Reference...

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Transcript of ieMR Quick Reference Guide Medication Administration · 2020. 10. 14. · ieMR Quick Reference...