The data came from various information sources including a patient's computerised hospital medical record, the admission medication orders, the physician-recorded MH, the nurse-recorded MH, interviews with patients, medication administration records and demographic information.
Operational definitions were documented for each variable, including a list of valid sources within a medical record (e.g., admission face sheet, surgical report, medication administration record), inclusion/exclusion criteria, time frame parameters, and medical terms/synonyms.
The data came from various information sources including a patient's computerised hospital medical record, F1, the physician-recorded medication history, the nurse-recorded medication history, interviews with patients, medication administration records and demographic information.
CPOE, computerized physician order entry; CRBSI, catheter-related bloodstream infection; DVT, deep vein thrombosis; EMR, electronic medical record; ICU, intensive care unit; MAR, medication administration record; PACS, picture archiving and communications system; VAP, ventilator-associated pneumonia.
A study conducted in prisons found that EAM for doses 'observed' by medical staff was lower than that documented in medication administration records [ 36], highlighting the importance of using consistent measurement techniques for self-administered and "observed" dosing.
In addition, in Edinburgh, use and timing of administration of treatments for anaphylactoid reactions and vomiting following commencement of NAC was routinely extracted from the medication administration record (drug kardex) in combination with the medical notes.
We instructed study sites to include all parts of the medical record, including the face sheet, admission note, daily progress notes, procedure notes, medication administration record, diagnostic procedure reports, laboratory test results, physician orders, nursing notes and discharge summary.
They also interface with electronic medication administration records.
This study sought to explore the relationship of workarounds related to the implementation of an electronic medication administration record and medication safety practices in five Midwestern nursing homes.
BCMA appeared to improve the safety of the processes of matching medications to the medication administration record and checking patient identification.
