PREPARATION FOR MEDICATION ADMINISTRATION CMT Training #2 The Center for Life Enrichment Resource: MTTP Student Manual 4 BASIC RULES There are “Four (4) Basic Rules” that must be followed when giving medication to an individual in a DD community-based agency such as TCLE 1. Unlicensed Assistant Personnel (UAP) may administer medications ONLY after the successful completion of the MTTP and certification by the Maryland Board of Nursing (MBON) as a Medication Technician (CMT) 2. Only RN case managers/delegating nurses (RN CM/DN) may delegate the administration of medications to CMTs who are staff of or under contract with the DD community based program 3. All medications must have a current Health Care Provider (HCP) order and a pharmacy label to be administered 4. All “over-the-counter” medications must have a current HCP order and a pharmacy label to be administered STAFF RESPONSIBILITIES IN ADMINISTERING MEDICATIONS As a CMT, you will be responsible for ensuring that individuals take their medications safely Administering medications safely requires following the Medication Administration Process/Cycle: 1. 2. 3. 4. 5. 6. 7. 8. Observing the individual for changes in physical condition and/or changes in behavior Reporting these observations to the RN CM/DN and supervisor in an appropriate time frame Assisting the individual in a visit to the HCP and communicating and obtaining all necessary information (May apply to CMTs providing ISS/CSLA support) Communicating with the pharmacist and obtaining the prescribed medication (i.e. new orders/refills) (May apply to CMTs providing ISS/CSLA support) Storing the medication safely Administering medications correctly Ensuring medications are taken Recording information promptly, correctly and on correct forms MEDICATION ADMINISTRATION RECORD (MAR) • • The MAR is a form used for documenting that medications have been administered as ordered Specific information must be recorded on the MAR when a new medication is received from the pharmacy and when a medication is administered: – The individual’s name, sex, & birth date – The name of the agency – The month and year of the record – Pertinent diagnoses – Any allergies the individual may have; “none known” should be written if none exists – The individual’s diet as ordered by the HCP (Health Care Professional) – The individual’s primary physician – The name of the delegating Registered Nurse responsible for follow-up and monitoring ADDING A MEDICATION TO A CURRENT MAR If there is a current MAR for the individual (meaning that other medications are already being given this month), and a new medication is ordered, then a new MAR does not have to be started The following information about the new medication can be added to the current MAR: Name of the medication Prescribed dose of the medication Route of the administration Times (frequency) of administration Start date is the most recent date on the signed HCP order The HCP must write a Discontinue Order for all medications/treatments. If applicable, this discontinued date is to be documented in the D/C column of the MAR Draw a horizontal line and arrow up to the exact date and time(s) the medication is to start REMEMBER, The MAR is a legal document! All information must be documented in blue or black ink Do not erase! Do not use whiteout! “3 WAY CHECK” Compare the HCP order, the Pharmacy Label, & MAR Make sure all 3 match! MEDICATION STORAGE • • • • • • All medications must be stored in the original containers in which they were dispensed by the pharmacist The pharmacy label should never be altered All medications must be grouped by the individual and stored centrally in a locked cabinet (area) The storage area must be locked when not in use The key to the locked medicine cabinet (area) or access to a lock combination should only be available to those individuals authorized to administer medications Refrigerated medications must also be kept in a locked storage container in the refrigerator DISPOSING OF MEDICATIONS • At times you may be responsible for disposing of medications. This may occur when: – – – – – The medication is discontinued before all of it is used The individual has refused to take the medication after it has been poured The medication is dropped on the floor or becomes contaminated in some other way The medication has expired The RN CM/DN will dispose of any Schedule II/Controlled Substances according to agency policy ANY QUESTIONS?