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please have your completed mall ready we will continue to build on this foundation in this lesson I will be teaching you how to update them our document medications that are not given the information that is documented on the back of them are and how to document the administration or supervision of the self administration of a PRN medication the Mar is a dynamic document and there will be times when you need to make changes medications may be added or discontinued the doctor's instructions may change the prescription may be time limited the reasons the Mar needs to be updated are numerous in this lesson we will look at the steps for making changes on the Mar how to document a medication that is not given and document the first three doses of a new medication as we work through please do not hesitate me at packet met at America org if you have questions or need a little more help understanding the process we will be using Jesse James's Mar that we completed in the last lesson go to your worksheet for the information for this exercise or copy it from this slide for your use as we work through the lesson I will use the step system again on July 8th at 1:00 a.m. jesse woke up screaming and severe pain you called your supervisor and she came in and took Jesse to the emergency room at 9:00 a.m. on July 8th when Jesse returned to the group home the doctor's diagnosis was a severe urinary tract infection he wrote the order for bactrim DSC below the prescription was sent to the pharmacy and will be available for the nighttime dose you called the primary healthcare provider and he agreed with the doctor's orders and sent the reconciliation information by fax bactrim D s 800 milligram / 60 milligram Pio every 12 hours for 14 days encourage Pio fluids prescription written by dr. Smith on July 8th 2019 we will add this time limit of prescription to the Mar let's review our steps for adding a medication to the Mahr step one and two double check the header to be sure everything is correct name month year and allergies please add any new allergies that are discovered then we move on to steps three and four adding the medication information to the Mahr one of the medication and the strength back from D s a hundred milligrams / 60 milligrams - right how many and what route take one tab by mouth three right how often and in this situation for how long every 12 hours for 14 days for right special instructions if applicable encourage fluids by mouth we finish entering the information by completing steps 5 & 6 writing the time the medication is to be given the order fits into the VI D standard times perfectly since they are 12 hours apartment the last thing that must be entered is the prescribers name which is dr. Smith and the date of the prescription which is 7 819 after entering all of the information for the bactrim go to the next slide and confirm your entry is correct make any Corrections if needed steps 1 through 6 have been completed please look over the entry carefully and note where everything from the prescription is recorded this is the format you should always use when adding a medication to the Mahr there's one more thing that needs to be done we have to indicate the starting and the ending date for the antibiotics since it is a time limited order I will show you how to do that on the next slide since Jessie wasn't prescribed the bactrim until the 8th of July and her first dose will not be available under the nighttime dose we will line out all of the squares from July 1st through July 8th 4 7 a.m. then we line out July 1st through the 7th / 7 p.m. since she will be getting her first dose at 7 p.m. on the 8th next we need to count the doses for the 14 days and line out the squares for the rest of the month since you will not have any doses do notice that the line out starts on the 22nd for 7:00 p.m. but starts on the 23rd for the 7 a.m. days after all the doses are given then you will need to discontinue the entry on the morrow I will show you how to do that on the next slide please line out the appropriate squares on your worksheet then go to the next slide when Jessie completes her antibiotics we need to discontinue it from the bar there are two steps first right the reason the medication was discontinued from the mark the date then your initials since this is time limited you would write completed the date and initial second take a yellow highlighter and yellow out the entire road use this process to update the bar whenever you have a change order or a discontinue order medication completed write completed the day the medication was completed and initial discontinued write discontinued the date and the medication was discontinued and your Nishal x' change order write order changed the date the medication was discontinued and initial see below after writing while you're removing the entry from the bar highlight the entire row with a yellow highlighter the discontinued medication orders should not appear on the next month's Mar if it is on the new mark notify the pharmacy or the person that prepares the Mars then write discontinued and the date the medication was discontinued and highlight the entire road remember to always line out doses not given if a medication is added to the bar and has not started on the first of the month before we move on to the next slide I would like you to take a moment to look at the 7 a.m. doses that were due on the eighth notice the initials are circled we will be talking about this and I will show you the required documentation associated with this situation when a dose of medication is missed regardless of the situation you must document the miss dose in complete a medication error report the documentation starts by you initially in the appropriate box and circling your initials if you look closely at the example you will see that PC circled her initials for both medications at 7:00 a.m. med pass remember jessie was still at the emergency room at that time a medication error report should be completed and the doctor's office must be called explain the situation and get written instructions concerning whether or not she should get the medication when she returns from the emergency room the documentation of the missed dose continues on the back of the mark I'll show you how to do that next before we continue I would like you to take a minute to think of reasons a medication dose is not given there are so many reasons that your client may miss a dose they are in the ER the family forgets you're stuck in traffic they refuse to take it the clinic hasn't responded to the pharmacies request for a refill order the list could go on and on regardless of the reason you will go through the same steps again write the steps down do whatever you need to remember them and make it your routine when documenting and dealing with a missed medication after initially in the box for the dose and circling it turn to the back of the Mahr and follow the steps below one write the date and time the dose was due to write the name and strength of the medication three write the reason the medicine wasn't given in the ER refused etc and any pertinent information for instance Jessie said she didn't want it I offered her meds several times before 8 p.m. for the last step is to initial the end of the column always be sure that you have signed and written your initials at the bottom of the page I would like to take a moment to share an experience when I was doing validations for a group home I noticed the ma P had drawn squares around the dais the medication was to be given then drew a line for the days it should not be given similar to the example on this slide the square around the initials could be confusing and as necessary my question is what would you do if the doctor tells you to hold a dose it would be difficult to see a circle around the square that is around the initials if you have an order that is not given daily either line out the squares or put an X in the boxes for the days the medication is to be skipped a person's medical situation changes so will his medications and treatments the next task we will be looking at combines the two that we've already learned again I encourage you to write down the steps and always approach recording changes to the more in a systematic way for this exercise we will make a change to occur in order please use the following information jesse is having frequent outbursts appears to be anxious most of the time and is having difficulty sleeping you made a doctor's appointment for July 24th at 10:00 a.m. dr. Jones made some changes to her medication he increased her routine dosage of ativan and gave you a PRN medication order for insomnia the pharmacy was able to fill the new prescriptions and get the medication to you for the evening med pass the doctor's orders are below ativan one milligram by mouth twice daily ambien five milligrams by mouth as needed for continued weight fulness that persists longer than one hour after going to bed for the night do not read Minister during the same night called a doctor for further instructions if she is unable to sleep for at least five hours the first step would be to discontinue the current order for ativan on the Mahr remember it is an automatic discontinue when you get a new order that changes the dose first you would write discontinued in the date second blackout all of the squares for the rest of the month then the last step is to highlight the entire row with yellow please enter the changes on your worksheet I will show you what it should look like on the next slide be sure your Mar looks the same if not make the necessary changes a quick review of the steps one right discontinue the date the medication is discontinued and your initials to line out the squares for the doses that were not given three highlight the entire row with yellow note the block for the seven pm on the 22nd is not lined out and you will be giving the news strength at 7 p.m. since the pharmacy was able to fill the new order and get the medication to the facility for the evening med pass now we need to add the new order for the ativan a quick review of the steps one write the name of the medication and the strength to write how many and what route three write how often for write special instructions if applicable 5 write the prescribing practitioners name and prescription date 6 write the timer times the medication is to be given be sure to update your worksheet before moving on to the next slide after you've entered the information the last step will be to line out all of the squares before the medication was started notice the morning dose on the 24th is lined out but the evening dose is not since it will be the first dose that is given on the next slide you will see the completed Mar with the change order make sure your worksheet looks the same if not make corrections we are not finished we still have to record the PRN medication that was ordered I will teach you how to do that in the next exercise take a few minutes to look over the Mar look at all the examples of tasks that you may have to do miss does discontinue you medication discontinuing a time-limited medication and adding a new medication that started partway into the month if you don't know how to do each and every one of these tasks without looking at your notes you will need to go back study and practice that procedure until you can do it in your sleep please notice I have signed off the first three doses of the new ativan order on the Mar remember you must directly observe the client for at least 20 minutes for the first three doses of a new medication and I'll servation oh and any reactions must be documented on the back of the Mahr if there was no reaction right no apparent reaction fill this information in on the back of your mark then click on the next slide to see how you did Anthea gave the first and the third dose and Cindy gave the second the date and time the medication name and strength the fact you observed the client the reaction to the medication if applicable must be documented always be sure you initial at the end of the line and confirm that you signed and initialed the bottom of the page be sure you update your worksheet and make any Corrections before continuing to the next slide I highly suggest that you use a separate page for your PRN medications since the instructions are entirely different prepare our and nebs you should easily be able to tell the difference however your efficiency will be affected if you have PRN meadows scattered through your scheduled or routine medications please take the blank Mar out of your worksheet and complete the entry for Genesee zambian which is a PRN medication use the same steps you learned for setting up a Mar page and adding a new medication I've completed the entry for the PRN medication for you double-check your worksheet and correct any errors on the next slide we will go through the steps to document the administration or supervision of a dose of a PRN medication the steps to document the administration or supervision of a PRN medication are below one read the order and confirm the dose may be given to check in the time column to see if there is a time that is the same as the dose you will be giving if not write the time in the time column three initial the appropriate box corresponding with the date and time for be sure you have signed in initial at the bottom of the page five document on the document you fill out your Mar using the information below Jessie told you I just can't go to sleep and ask for her sleeping pill in the exercise we will be documenting three doses than documenting them on the back of the mark July 24th she asked for her sleeping pill at 9:00 p.m. July 25th she asked for her sleeping pill at 9:15 p.m. July 26 she asked for her sleeping pill at 11:00 p.m. document the doses and times on the front of the mark then go to the next slide and check your work update the worksheet before going to the next slide look how the doses were documented on the front of the bar Anthea gave Jessie the first dose at 9:00 p.m. on the 24th and the second dose at 9:15 on the 25th notice how she signed the medication off on the front of the mark John gave the third dose 11:00 p.m. on the 26th make any corrections to your worksheet then go to the next slide this is the first step in documenting the administration of PRN medications let's go to the back of the Mar and complete the documentation you will be documenting the reason and the response for the PRN medication and the observation for the first three doses of a new medication since the ambient is a new to order remember anthea gave the first and second doses John gave the third dose for the first three doses you will document both the information needed for the PRN administration and the 20-minute observation remember for PRN document date/time medication name and strength why you gave the medication and around 30 minutes later the clients response to the medication for the first three doses of a new medication you will document that you observe the person for 20 minutes and how they reacted to the medication if there is no reaction notice then you would document that just write what you see document all three days of the medication that was given to Jessie use the information that was supplied to you for the documentation on the front of the Mar when you have finished go to the next slide and see how you did make any correction anthea gave the first and second doses John gave the third dose for the first three doses you will document both the information needed for a PRN administration and the twenty minute observation remember for PRN document date/time medication and strength y-you gave the medication and around 30 minutes later the clients response to the medication okay this finishes up the documentation for the Mar be sure you have completed your worksheet Mar and Corrections if any have been made you may use this to study for your more exam to help you remember all of the steps and parts for completing various tasks needed for documentation on the mar again if you have any questions concerning more documentation please email me at Pat at med ed america org and i will be more than happy to help next we will be looking at what information and documents are required to be in your marble