Can you chart a medication that you have not prepared or given?

The policy surrounding medication management emphasizes accountability and accuracy in patient care. Charting a medication that you have not prepared or administered compromises the integrity of the medical record and poses significant risks to patient safety. Such practices can lead to tracking errors, miscommunication about patient care, and potential harm if another caregiver acts based on inaccurate information.

When healthcare professionals are involved, each one must accurately document their actions to ensure proper continuity of care and to maintain legal and ethical standards. The protocols are designed to uphold these principles, and any deviation from them undermines the reliability of the healthcare system. Thus, it is essential that only those who have actually prepared and administered the medication document it in the patient's record to provide a clear and truthful account of care.