Nursing Clinical Progress Note [Insert agency-specific skilled nursing note and instructions.] The nursing clinical progress note is used to document the care provided on each nursing visit. It also provides a place for documentation of both home health aide and LVN/LPN supervisory visits. Ask the supervisor for instructions on how to complete the progress note. Medication Safety and Compliance The RN will complete a comprehensive assessment of the patient/client and will document any allergies, side effects or adverse effects of medications. The nurse will also assess the patient’s/client’s knowledge of and compliance with the medication regimen. The nurse will include an assessment of the patient’s/client’s physical and cognitive ability to safely manage the medications with or without reminders. The nurse will assess if the patient/client has adequate financial resources to obtain needed medications and may refer to social services for additional resources if needed. The nurse will complete the medication profile, listing all prescription and over-the-counter (OTC) medications, herbal remedies, samples, vitamins, and minerals. The nurse will review the medication list for potential contraindications, duplications, adverse reactions, and food and drug interactions at admission and as medications are newly ordered (within 30 days), changed (within 60 days), or discontinued. The medication list must be kept current and updated to reflect all medication changes. A copy of the medication list without abbreviations is left in the patient’s/client’s home and is kept updated. The plan of care should include teaching the patient/client and/or caregiver about the medications including proper storage, how to take the medication, the purpose, expected effects, and possible side effects of each medication. A reminder system such as a pillbox may be used to help the patient/client comply with the regimen. It is important to remember the filling of a pillbox is not a skilled service under the Medicare benefit. However, teaching a patient/client or caregiver how to use the pill box is skilled. The patient’s/client’s response to the medication regimen should be routinely assessed and any adverse reactions or complications must be reported to the physician. There must be an order from a physician and/or non-physician practitioner for a nurse to administer any medication (or treatment) before it is given to the patient/client. The nurse administering medication or delegating the administration of medication must be qualified and must follow all the regulations established by the state’s board of nursing. Please refer to the state’s nursing practice act. In addition to the nursing practice act, the nurse must follow other rules including the state’s licensing standards, Medicare’s rules, and the Agency’s policies on the administration of medication. The nurse should follow the rights of medication administration set by nursing standards. There might be medication errors made by the nurse, patient/client, or caregiver. These must be reported immediately and documented according to the Agency’s policy.
