What must be documented for every medication administered to a resident?

Documenting the date and time, along with the dosage and route of medication administered to a resident, is essential for several reasons. This practice ensures that there is a clear and accurate medical record reflecting the specific details of each medication given.

Timely documentation helps in tracking the medication administration to prevent errors, manage dosages, and understand the timeline in relation to the resident's treatment plan. Additionally, noting the route of administration is crucial for understanding how the medication was delivered, as this can significantly impact its effectiveness and the resident's response. Proper recording supports compliance with regulatory standards and provides necessary information for other healthcare providers involved in the resident's care. Ultimately, these detailed records contribute to the safe and effective management of medications within nursing care institutions.