Final answer:
To ensure full visibility of a patient's current medications when starting a new one, it should be documented in the medication administration record (MAR) and reviewed with the healthcare team for accuracy.
Step-by-step explanation:
When starting a patient on a new medication that they have never received before, it is essential to document this addition accurately to maintain a full and up-to-date list of the patient's current medications. To ensure proper documentation, this information should be recorded in the patient's medical chart or electronic health record (EHR). Specifically, the medication administration record (MAR) should be updated with the new medication, including details such as the name of the medication, dosage, route of administration, frequency, and specific instructions for use.
The nurse should review the updated MAR with the healthcare team, confirming that the information is recorded correctly and clearly understood by all. This review process might include a safety check, to which a nurse reviews items aloud with the team, such as:
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- The name of the procedure as recorded
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- Whether needle, sponge, and instrument counts are complete, or not applicable
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- That any specimen (if any) is correctly labeled, including with the patient's name
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- Whether there are any issues with equipment to be addressed
This thorough documentation and verification process helps to minimize the risk of medication errors and ensures that all healthcare providers are aware of the new addition to the patient's medication regimen.