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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 1032 (February 24, 2024).

55 Pa. Code § 2390.195. Medication record.

§ 2390.195. Medication record.

 (a)  A medication record shall be kept, including the following for each client for whom a prescription medication is administered:

   (1)  Client’s name.

   (2)  Name of the prescriber.

   (3)  Drug allergies.

   (4)  Name of medication.

   (5)  Strength of medication.

   (6)  Dosage form.

   (7)  Dose of medication.

   (8)  Route of administration.

   (9)  Frequency of administration.

   (10)  Administration times.

   (11)  Diagnosis or purpose for the medication, including pro re nata.

   (12)  Date and time of medication administration.

   (13)  Name and initials of the person administering the medication.

   (14)  Duration of treatment, if applicable.

   (15)  Special precautions, if applicable.

   (16)  Side effects of the medication, if applicable.

 (b)  The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.

 (c)  If a client refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the client.

 (d)  The directions of the prescriber shall be followed.


   The provisions of this §  2390.195 issued under sections 201(2), 403(b), 403.1(a) and (b), 911 and 1021 of the Human Services Code (62 P.S. § §  201(2), 403(b), 403.1(a) and (b), 911 and 1021); and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. §  4201(2)).


   The provisions of this §  2390.195 adopted October 4, 2019, effective in 120 days, 49 Pa.B. 5777.

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