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The nurse can then scan the bar code on medication and use software to verify that he/she is administering the right medication to the right patient at the right dose, through the right route, and at the right time ("five rights of medication administration"). [5] Bar code medication administration was designed as an additional check to aid the ...
Medication management is a difficult task, where it focuses on the "five rights": right patient, right medication, right dose, right time, and right route of administration. [7] Barcode medication verification at bedside allows for nurses to automatically document the administration of drugs by means of barcode scanning.
Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
Medication is an intervention that can turn a person's status from stable to unstable very quickly. With paper documentation it is very easy to not properly document the administration of medication, the time given, or errors such as giving the "wrong drug, dose, form, or not checking for allergies" and could affect the patient negatively.
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Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...