37.106.2849 MEDICATIONS: RECORDS AND DOCUMENTATION
(1) An accurate medication record for each resident shall be kept of all medications, including over-the-counter medications, for those residents whose self-administration of medication requires monitoring and/or assistance by the facility staff.
(2) The record shall include:
(a) name of medication, reason for use, dosage, route, and date and time given;
(b) name of the prescribing practitioner and their telephone number;
(c) any adverse reaction, unexpected effects of medication, or medication error, which must also be reported to the resident's practitioner;
(d) allergies and sensitivities, if any;
(e) resident specific parameters and instructions for PRN medications;
(i) documentation of when and why a PRN was administered or self-administered and follow up documentation as to the effectiveness of the PRN;
(f) documentation of treatments with resident specific parameters;
(g) documentation of doses missed or refused by resident and why;
(h) initials of the person monitoring and/or assisting with self-administration of medication; and
(i) review date and name of reviewer.
(3) When using paper Medication Administration Records (MARs), the facility shall maintain legible signatures of staff who monitor and/or assist with the self-administration of medication, either on the medication administration record or on a separate signature page. Electronic MARs must include the names associated with the initials of those staff documenting administration of medications.
(4) A medication record need not be kept for those residents for whom written authorization has been given by their practitioner to keep their medication in their rooms and to be fully responsible for taking the medication in the correct dosage and at the proper time. The authorization must be renewed on an annual basis.
(5) The facility shall maintain a record of all destroyed or returned medications in the resident's record or closed resident file in the case of resident transfer or discharge.