Close

Documentation

When administering medication, documentation is essential to communicate outcomes and prevent errors – such as accidentally missed doses or double dosing. When preparing and administering medications, a copy of the order (care plan) should be used as a reference to check the correct dosage three times, as follows:

9

First when one identifies the vial/syringe/bottle/bag/powder/capsule/tablet the medication is packaged in;

9

Secondly when one is preparing the medication; and

9

Thirdly after one has completed the preparation process.

When dispensing medication, the following documentation is required:

9

Patient/client name, contact information, birth date and gender;

9

Any allergies and adverse reactions;

9

Date, time and (if appropriate) the location that the dispensing took place;

9

Medication name, strength, dose and quantity dispensed;

9

Length of therapy;

9

Any instructions provided to patient/client;

9

RT’s signature and professional designation; and

9

Any other relevant information.

Documentation, in the event of a patient refusal of medication, is very important.

GLOSSARY

Administration (of a medication): the direct application of a drug to the body of a specific patient or research subject by injection, inhalation, ingestion, or any other means.

Authority: the right to act, as outlined in the legislation, usually related to terms, conditions or limitations imposed on a certificate of registration.

Controlled act: one of the 13 acts defined in the RHPA [section 27(2)]

Compounding: the act of combining two or more elements to create a distinct pharmaceutical product. Compounding is not authorized to Respiratory Therapists. Delegation is not required when combining elements to prepare a drug for administration. For example: mixing liquid bronchodilators in normal saline for aerosolized therapy.

Competence: having the requisite knowledge, skills and judgement/abilities to perform safely, effectively and ethically; and applying that knowledge, skills and judgement/abilities to ensure safe, effective and ethical outcomes for the patient/client.

Delegation: the transfer of the legal authority to perform a procedure within a controlled act to a person not otherwise authorized to perform the procedure.

Drug: as defined in the Drug and Pharmacies Regulation Act.

Labelling: the process of preparing and affixing a label to any drug container. Any such label shall include all information required by provincial regulations. In this context, labelling does not include the labelling by the manufacturer, packer or distributor of a non-prescription drug or commercially packaged drug or device.

Order: An “order” is the authority to undertake an intervention if the circumstances are appropriate and, in your professional judgement, it is appropriate to undertake the intervention. For more information of what constitutes a valid order, please see the Orders for Medication Care PPG.

Pharmacy: a premise in or in part of which prescriptions are compounded or dispensed for the public.

Prescriber: a person authorized to give a prescription within the scope of his or her practice of a health discipline or profession.

Prescription: an authorization from a prescriber permitting the dispensing of any drug or mixture of drugs for a designated person or animal.

Regulated health care professional — a health care provider who is a member of a CRTO and is regulated by the RHPA (e.g., nurse, physician, dentist, massage therapist, physiotherapist, dietitian, occupational therapist, etc).

Respiratory Therapists: Members of the CRTO (RRT, GRT, PRT).

REFERENCES
  1. National Association of Pharmacy Regulatory Authorities National Drug Schedules | NAPRA
  2. The Nine Rights of Medication Administration. British Journal of Nursing (2010) Vol.19, Number 5. Elliot, Liu. http://publicationslist.org/data/m.elliott/ref-2/Nine%20medication%20rights.pdf
  3. Hughes RG, Blegen MA. Medication Administration Safety. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 37. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2656/
  4. Ontario College of Pharmacists (OCP). (2006). Policy Respecting the Distribution of Medication Samples. Retrieved from OCP website at http://www.ocpinfo.com/regulations-standards/policies-guidelines/distribution-samples/
  5. College of Physicians and Surgeons of Ontario. (2019). Prescribing drugs. CPSO Policies. Retrieved from https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Prescribing-Drugs
  6. Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B. T. (2008). Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423.
  7. Ontario College of Pharmacists (OCP). (2006). Policy Respecting the Distribution of Medication Samples. Retrieved from OCP website at http://www.ocpinfo.com/regulations-standards/policies-guidelines/distribution-samples/
  8. College of Nurses of Ontario (CNO) Medication Practice Standard (2017). Retrieved from the CNO website at: https://www.cno.org/globalassets/docs/prac/41007_medication.pdf
  9. Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B. T. (2008). Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423.
  10. College of Nurses of Ontario (CNO). Nurse Practioner Practice Standard (2021). Retrieved from the CNO website at: https://www.cno.org/globalassets/docs/prac/41038_strdrnec.pdf
  11. College of Midwives of Ontario (CMO). Midwifery Scope of Practice (2021). Retrieved from the CMO website at: https://www.cmo.on.ca/wp-content/uploads/2021/04/Midwifery-Scope-of-Practice.pdf#:~:text=delivery%20of%20a%20baby4%20is%20authorized%20to%20physicians,manage%20labour%20and%20conduct%20spontaneous%20normal%20vaginal%20deliveries5.
  12. College of Nurses of Ontario (CNO). Authorizing Mechanisms (2020). Retrieved from the CNO website at: https://www.cno.org/globalassets/docs/prac/41075_authorizingmech.pdf
  13. Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Reduction and Prevention. [Updated 2022 Jan 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499956/