What must be documented after medication administration?

Documenting after medication administration is a critical practice in nursing and pharmacology as it ensures accurate patient records and promotes patient safety. The correct answer includes the medication name, dosage, route, time, and the patient’s response.

This comprehensive documentation serves several vital purposes. Firstly, it provides a clear record of what medication was administered, including the correct dosage and the method of delivery (whether it was oral, intravenous, etc.), which is essential for continuity of care. The timing of administration helps to track the medication schedule and avoid potential overlaps or omissions in patient treatment.

Equally important is documenting the patient's response to the medication, which can reveal effectiveness or any adverse effects that may require further medical intervention. This information is crucial for evaluating the therapeutic outcome and making necessary adjustments to the treatment plan. The overall documentation thus supports communication among healthcare providers, enhances patient safety, and contributes to high-quality patient care.