Medication Administration Record
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Department of Health and Human Services MAINE Division of Licensing and Certification CiSiP September 2005 The Maine Department of Health and Human Services does not discriminate against people on the basis of disability, race, color, creed, gender, age or national origin in admission to, access to, or operations of its programs, services or activities, or its hiring or employment practices. This information is available in alternate format upon request. CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 2 of 177 TABLE OF CONTENTS Section 1..................................................................................................................9 CRMA Role............................................................................................................9 • Certification Limitations......................................................................................................................... 9 • Job Description..................................................................................................................................... 10 • Other Staff Roles................................................................................................................................... 10 • Key Responsibilities............................................................................................................................. 10 • Characteristics....................................................................................................................................... 10 Section 2................................................................................................................11 INSTRUCTIONS FOR DOCUMENTATION EXERCISE ...........................11 PHYSICIAN’S ORDERS ...................................................................................12 RESIDENT CARE NOTES................................................................................13 Medication Administration Record......................................................................14 Medication Disposal Form................................................................................................................................ 16 Medication Error Form............................................................................................................................... 17 Medication Sign Out Record Form ......................................................................................................... 18 Missed or Late Medications ...................................................................................................................... 19 Over The Counter Medication Form....................................................................................................... 20 Physician’s Order......................................................................................................................................... 21 CRMA – RECERT Medication Administration Skills Checklist.................................................................... 22 Section 3................................................................................................................25 MEDICAL ABBREVIATIONS.........................................................................25 Section 4................................................................................................................28 MEDICATION MEASUREMENTS.................................................................28 Systems of Measurement..................................................................................................................... 28 • Metric Terms......................................................................................................................................... 28 • Apothecary System Description ........................................................................................................... 29 • Household System Description............................................................................................................. 29 • Metric System ....................................................................................................................................... 29 • Weight................................................................................................................................................... 29 CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 3 of 177 • Volume.................................................................................................................................................. 30 • Length ................................................................................................................................................... 30 Apothecary System................................................................................................................................. 30 • Weight -- (Dry) ..................................................................................................................................... 30 • Volume -- (Wet).................................................................................................................................... 30 Household System .................................................................................................................................. 31 Equivalent Dry Measurement Units............................................................................................... 31 Equivalent Liquid Measurement Units......................................................................................... 32 Section 5................................................................................................................33 Review of Drug Classifications...........................................................................33 Medication Classification Terms and Definitions ............................................33 Section 6................................................................................................................36 Medication Orders ..............................................................................................36 • Obtaining Medication Orders ............................................................................................................... 36 • Prescription ........................................................................................................................................... 36 • Duly Authorized Licensed Practitioner Order ...................................................................................... 36 Psychotropic PRN’s..................................................................................................................................... 37 Calling In Orders.......................................................................................................................................... 37 Appointment for Service/Order Sheet .................................................................................................... 37 Telephone Orders......................................................................................................................................... 38 When Must Orders be Written or Re-Written?...............................................38 During the Admission Process.................................................................................................................. 38 Psychotropic Orders .................................................................................................................................... 38 Medical Orders ............................................................................................................................................. 39 Upon Discharge from a Hospitalization................................................................................................. 39 New Orders.................................................................................................................................................... 39 Changed Orders............................................................................................................................................ 40 Discontinued or Stop Orders..................................................................................................................... 41 Section 7................................................................................................................42 Medication Ordering........................................................................................................................ 42 SECTION 8..........................................................................................................43 CRMA RECERTIFICATION CURRICULUM SEPTEMBER 2005 Page 4 of 177 Documentation.....................................................................................................43 • Initials ................................................................................................................................................... 43 • Unusual Circumstances......................................................................................................................... 43 • Refusal .................................................................................................................................................. 43 Medication Administration Record (MAR)......................................................44 General Information ...................................................................................................................................