Section 2800.187. Medication records

(a) A medication record shall be kept to include the following for each resident for whom medications are administered:

(1) Resident’s name.

(2) Drug allergies.

(3) Name of medication.

(4) Strength.

(5) Dosage form.

(6) Dose.

(7) Route of administration.

(8) Frequency of administration.

(9) Administration times.

(10) Duration of therapy, if applicable.

(11) Special precautions, if applicable.

(12) Diagnosis or purpose for the medication, including pro re nata (PRN).

(13) Date and time of medication administration.

(14) Name and initials of the staff person administering the medication.

(b) The information in subsection (a)(13) and (14) shall be recorded at the time the medication is administered.

(c) If a resident refuses to take a prescribed medication, the refusal shall be documented in the resident’s record and on the medication record. The refusal shall be reported to the prescriber within 24 hours, unless otherwise instructed by the prescriber. Subsequent refusals to take a prescribed medication shall be reported as required by the prescriber.

(d) The residence shall follow the directions of the prescriber.

Notation

Cross References

This section cited in 55 Pa. Code § 2800.182 (relating to medication administration).