> For the complete documentation index, see [llms.txt](https://edehr.gitbook.io/edehr-compass/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://edehr.gitbook.io/edehr-compass/educational-implementation/simtech-support-guide/simulation-technologist-support-guide/medication-administration-documentation.md).

# Medication Administration Documentation

### Medication Administration Documentation on EdEHR

This guide outlines the technical steps and best practices for documenting medication administration using EdEHR. It is intended to support educators, simulation technologists, and faculty in ensuring safe, accurate, and complete records during simulation or skills lab activities. For clinical procedures, always refer to your institution’s protocols.

#### Who Should Use This Guide

* Simulation educators and faculty
* Simulation technologists
* Students practicing medication administration in simulation or lab settings

#### Key Considerations

* This guide focuses on documentation within EdEHR, not the clinical administration process itself.
* Ensure all users are familiar with the EdEHR platform and have completed orientation.
* Always follow your institution’s medication safety and documentation policies.

## Step-by-Step Documentation Process

{% stepper %}
{% step %}

### **Administer the Medication**

Follow your standard medication administration procedures (the “rights” of medication administration: right patient, medication, dose, time, and route). Once the medication has been given, proceed to document in EdEHR.
{% endstep %}

{% step %}

### Identify Scanned Medications

Medications that have been scanned using the barcode scanner will be highlighted in blue on the EdEHR interface.

<mark style="background-color:blue;">SCREENSHOT</mark>
{% endstep %}

{% step %}

### Document the Administration

Click the blue pencil icon next to the medication you administered. A Medication Administration pop-up will appear.

<mark style="background-color:blue;">SCREENSHOT</mark>
{% endstep %}

{% step %}

### Complete Documentation Fields

* Fill in all required fields in the pop-up (e.g., dose, route, time administered, any relevant notes).
* Adjust the time of the event if needed for accuracy.
* Click “Save” to record the entry.
* Click “Verify” to confirm and finalize the documentation.

<mark style="background-color:blue;">SCREENSHOT</mark>
{% endstep %}

{% step %}

### Fluid Balance Documentation

* Fluid balance is not automatically calculated in EdEHR.
* To document fluids:
  * Go to Current Visit, then select Fluid Balance.
  * Click “Add a fluid record.”
  * Enter the necessary details (e.g., fluids given, comments).
  * Save and verify the record.

<mark style="background-color:blue;">SCREENSHOT</mark>
{% endstep %}

{% step %}

### Review & Confirm

* Ensure all medication administrations and fluids have been documented and verified.
* Double-check for any missed entries or errors before ending the session.
  {% endstep %}
  {% endstepper %}

#### Additional Tips

* Document medication administration as soon as possible after giving the medication to maintain accuracy.

**For more detailed clinical procedures, consult your institution’s medication administration policy. For questions about EdEHR features or troubleshooting, contact your simulation technology support team.**


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