What is generally included in medication pass documentation?

Documentation of medication passing is crucial for ensuring proper patient care and accountability. Including the specific time and dosage given is essential for several reasons. Firstly, it allows for tracking whether the patient receives medications as prescribed, which is vital for medication effectiveness and patient safety. Accurate documentation provides a clear record of what was administered, thereby aiding healthcare professionals in assessing patient responses to treatment and making informed decisions about ongoing care. It also serves as a legal record that can be referenced if any questions arise about the medication administered.

In contrast, personal notes and observations, while important in some contexts, are not standard elements of medication documentation; they may be subjective and not necessarily relevant to the precise administration of medication. Only recording the patient's name or just the medication name would provide insufficient detail for accountability and safety, as these do not include critical information regarding the specifics of the medication administration process, such as timing and dosing.