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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 7346 (November 25, 2023).

55 Pa. Code § 6100.465. Medication record.

§ 6100.465. Medication record.

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

   (1)  Individual’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 an individual 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 individual.

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

Cross References

   This section cited in 55 Pa. Code §  6100.469 (relating to exceptions); 55 Pa. Code §  6100.802 (relating to support coordination, targeted support management and base-funding support coordination); 55 Pa. Code §  6100.803 (relating to organized health care delivery system); and 55 Pa. Code §  6100.804 (relating to base-funding).

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