Missouri Department of Health & Senior Services

1.

Check Order

Verify presence of a current, complete, signed physician’s order in the client record or protocol in the agency. Physician’s orders and/or protocols must be rewritten or reviewed, signed and dated at least yearly, or more often if indicated.

Individual medical orders to dispense medication must contain:

• Client’s name, if the order is not written on client’s record;
• Name of medication;
• Strength, dosage and frequency of medication;
• Quantity of medication to dispense;
• Method of administration;
• Date order written;
• Number of refills (if applicable); and
• Physician’s original signature (stamps are not acceptable).

Telephone orders:

• Should be accepted only under unusual circumstances;
• May be taken by an RN or LPN;
• Must be documented in the client record;
• Must be signed by the nurse taking the order;
• Requires a signed copy of the order from the physician; and
• May not be refilled if the physician’s order is not signed.

Protocol or Standing Orders must include:

• Medical order for the medication;
• Name of medication;
• Strength of medication (as per age, weight, condition, etc.);
• Frequency medication is to be taken (as per condition, etc.);
• Exact dosage (as per age, weight, condition, etc.);
• Quantity of medication;
• Method of administration (as per age or condition, etc.);
• Permission to refill;
• Condition for which the medication would be dispensed. Example: for client who has positive GC culture;
• Signatures of physician(s) and registered nurse(s) implementing the protocol; and
• Date signed.

The copies of the applicable protocol or standing orders should be available at each clinic and in the health unit office for immediate reference. The original should be kept in a permanent file.

2.

Assess Client

Assess the client’s condition including:

• Need for medication;
• Contraindications, i.e., allergic reactions;
• Signs and symptoms of side effects; and
• Compliance with treatment.

Medication should NOT be provided if in the registered nurse’s judgment:

• Client’s condition contraindicates further medication until the nurse has conferred with the physician;
• The patient’s/familys ability to be responsible for a quantity of medications is highly questionable. The physician should be consulted.
• The label is inaccurate on prelabeled medications. In this case, the nurse should consult with the person who dispensed the medication;
• The physician’s order is unclear, incomplete, or questionable. The nurse should consult with the physician to clarify order before making the decision whether to provide the medication or refer to the physician;
• Medication is outdated, obviously contaminated or otherwise compromised; and
• Medication has not been stored properly.
  

3.

Label Medication

4 CSR 150-5.020 and 4 CSR 200-4.200 outline the requirements for labeling of all medications.

The label must contain:

• Date medication dispensed;
• Sequential number;
• Client name;
• Prescriber’s direction for usage including frequency and route of administration;
• Prescriber’s name;
• Name and address of the agency dispensing;
• Name and strength of the drug dispensed;
• Quantity dispensed; and
• Number of times refillable, if appropriate or the words “no refill.”

Labels may be filled in by a clerk, but the label must be checked against the order and manufacturer’s label on package and affixed by an R.N., physician, or pharmacist.

All medications should be dispensed in childproof containers. Blister packets are considered childproof.

4.

Document in Dispensing Record

State regulations (4-CSR 150.5.020, 4 CSR 200-4.200) outline the requirements that must be followed for dispensing medications. Any RN dispensing medications must maintain required records to guarantee security, storage, and accountability. All medications dispensed from a local public health agency should be kept in a secure location, labeled, sequentially numbered, and logged.

Medication Log

• A log is to be established as a continuous record for accountability of all medications dispensed to clients of the health unit;
• Each page of the log must be retained for five years from the last entry date on the page;
• A separate log may be established for clinics held away from the health unit or that are held simultaneously;
• All logs are considered confidential information and should be handled accordingly;
• The log for sexually transmitted disease medications should be handled with the same confidential procedure as other STD records; and
• When separate logs are kept, a central record should be kept on where the logs are located and what groups are recorded in each log.

The log shall contain:

• Sequential number;
• Client’s name;
• Name of medication;
• Manufacturer and lot number;
• Strength and quantity of medication;
• Name of RN dispensing medication; and
• Date medications dispensed.

Sequential Numbering
Sequential numbers are assigned to medications (Tuberculosis medications have sequential numbers assigned by the state - contract pharmacy, and should not be relabeled. The sequential number should be logged.)

Determine what the beginning number will be, and as each new medication is dispensed, the next number in sequence is assigned and recorded on the label.

If there are separate record books for logging the numbers, a number code should be designated for each book.

5.

Provide Information to Client

The following information should be given to the client family:

• Condition for which the medication has been prescribed;
• Effects of medication, expected and untoward actions;
• How, when, what, and amount of medication to take;
• Other factors as indicated by client need and type of medication;
• When, who and where to contact in case of an adverse reaction;
• Other appropriate interventions as indicated by the assessment; and
• Warning to keep the medications out of the reach of children.

6.

Check Medication

Before the client/family leaves with the medication, check the following:

• The medication manufacturer’s label, including expiration date, against the physician’s written order;
• The sequential number and medication have been logged; and
• The label is complete and correct.

7.

Document in Client's Record

The following must be recorded in client’s record:

• Findings of assessment which indicate or contraindicate need for medication. If medication is not dispensed, the reason why;
• Reference to medical order. Individual orders are to be kept in the client record. Protocols or standing orders are to be kept on permanent file with updates and changes. The protocol should be referenced in the client record documentation or a copy of the protocol be included in the record;
• Name of medication dispensed, strength, dose, route, frequency and amount dispensed;
• Sequential number (optional);
• Signature of registered nurse dispensing medication; and
• Current date.

Reference
4 CSR 150-.5.020-Nonpharmacy Dispensing
4 CSR 200-4.200-Collaborative Practice Rule
Chapter 335 RSMo-State of Missouri Nursing Practice Act
Physicians Desk Reference