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37.106.2886    MEDICATIONS: RECORDS AND DOCUMENTATION: CATEGORY B

(1) An accurate medication record for each resident shall be kept of all medications, including over-the-counter medications, administered by the facility to that resident.

(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;

(f) documentation of treatments with resident specific parameters;

(g) documentation of doses missed or refused by resident and why; and

(h) initials of the person administering the medication and treatment at the time of administration.

(3) The facility shall maintain legible signatures of staff who administer medication or treatment, either on the medication administration record or on a separate signature page.

(4) A medication record need not be kept for those residents for whom written authorization has been given by their physician or 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.

History: Sec. 50-5-103, 50-5-226 and 50-5-227, MCA; IMP, Sec. 50-5-225, 50-5-226 and 50-5-227, MCA; NEW, 2002 MAR p. 3638, Eff. 12/27/02.

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