TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 116 ADMINISTRATION OF MEDICATION IN COMMUNITY SETTINGS
SECTION 116.70 MEDICATION ADMINISTRATION RECORD AND REQUIRED DOCUMENTATION


 

Section 116.70  Medication Administration Record and Required Documentation

 

a)         All medications, including patent or proprietary medications (e.g., cathartics, headache remedies, or vitamins, but not limited to those) shall be given only upon the written order of a physician, advanced practice nurse, or physician assistant.  Rubber stamp signatures are not acceptable.  All orders shall be given as prescribed by the physician and at the designated time.  Telephone orders may be taken by a registered professional nurse or licensed practical nurse.  All orders shall be immediately written on the individual's clinical record or a "telephone order form" and signed by the nurse taking the order.  These orders shall be countersigned or documented by facsimile prescription by the physician within ten working days.

 

b)         Medication Administration Record

 

1)         An individual medication administration record shall be kept for each individual for medications administered and shall contain at least the following:

 

A)        the individual's name;

 

B)        the name and dosage form of the drug;

 

C)        the name of the prescribing physician, physician assistant, dentist, podiatrist, or certified optometrist;

 

D)        dose;

 

E)        frequency or times of administration;

 

F)         route of administration;

 

G)        date and time given;

 

H)        most recent date of the order;

 

I)         allergies to medication; and

 

J)         special considerations.

 

2)         The medication administration record for the current month shall be kept with the medications or in the individual's clinical record.  If logs are kept in the individual's clinical record, the record shall be present when and where the medications are taken so that the appropriate notation can be made in the log.

 

3)         The medication administration record shall be completed and initialed immediately after the medication is administered by the authorized direct care staff.  Each medication administration record shall have a section that contains the full signature and title of each individual who initials the medication administration record.

 

4)         All changes in medication shall be noted on the medication administration record by a licensed practical nurse, registered professional nurse, advanced practice nurse, pharmacist, physician, physician assistant, dentist, podiatrist, or certified optometrist and reported to the registered professional nurse in charge of the program prior to the next dose.

 

5)         Individual refusal to take medications shall be noted in the medication administration record.  A progress note by authorized direct care staff shall be written in the individual's clinical record indicating the reasons for refusal and the registered professional nurse shall be notified.

 

6)         For individuals who are independently self-administering medications, no medication administration record shall be required.  However, any medication that individuals take shall be listed in their clinical records, including dosage, frequency, and identity of the prescribing physician, physician assistant, dentist, podiatrist, or certified optometrist.  Each agency shall develop and implement a quality assurance system to ensure that self-administered medications are taken in accordance with prescribed orders.

 

c)         In the event of a medication error, authorized direct care staff shall immediately report the error to the registered professional nurse, advanced practice nurse, physician, physician assistant, dentist, podiatrist, or certified optometrist to receive direction on any action to be taken.  All medication errors shall be documented in the individual's clinical record and a medication error report shall be completed within eight hours or before the end of the shift in which the error was discovered, whichever is earlier.  The medication error report shall be sent to the nurse-trainer for review and further action.  A copy of the medication error report shall be maintained as part of the agency's quality assurance program.  Medication errors must be reported to the DHS Bureau of Quality Enhancement (or the Illinois Department of Public Health Regional Office if an individual of an ICF/DD-16 is involved) in accordance with written instructions from the Department's Bureau of Quality Enhancement or DPH rules (77 Ill. Adm. Code 350). All medication errors are subject to review by DHS or DPH, whichever is applicable.  Medication errors that meet the reporting criteria pursuant to the Department's rules on Office of Inspector General Investigations of Alleged Abuse or Neglect or Deaths in State-Operated and Community Agency Facilities (59 Ill. Adm. Code 50) shall be reported to the Office of Inspector General.

 

d)         In the event of suspected drug reaction, authorized direct care staff shall immediately report the signs and symptoms to the registered professional nurse, advanced practice nurse, physician, physician assistant, dentist, podiatrist, or certified optometrist to receive direction on any action to be taken.  All adverse drug reactions shall be documented in the individual's clinical record and an adverse drug reaction report shall be completed within eight hours or before the end of the shift in which the reaction was discovered, whichever is earlier.  The adverse drug reaction report shall be sent to the prescriber and the nurse-trainer for review and further action.  A copy of the adverse drug reaction report shall be maintained as a part of the agency's quality assurance program.

 

e)         An inventory and a record of use of controlled substances shall be maintained by the registered professional nurse in the program, and each substance shall require a separate sheet indicating the:

 

1)         name of the individual;

 

2)         name of the prescriber;

 

3)         serial number of the prescription;

 

4)         name of the drug and strength;

 

5)         amount used;

 

6)         amount remaining;

 

7)         time and date administered;

 

8)         name of the individual who administered the medication; and

 

9)         documentation of a shift count done by authorized direct care staff.  Any discrepancies shall be reported to the nurse-trainer for review and action in accordance with written policy.