Responsibilities Following Drug Administration: Documentation - Video Lesson

Hey, everybody. Welcome back to another lesson about medication administration. This lesson focuses on post medication administration responsibilities, including focuses on charting techniques and the importance of accurate documentation and error reporting in health care. There are many ways of documenting in various health care settings. One way of documenting is the problem oriented medical record or POMR. The POMR is designed to make sure that all members of the health care team are aware of what others are doing and planning for the patient. It provides a structured format for tracking the patient's status and the care provided over time. The POMR includes a comprehensive collection of the patient's personal and health information as well as a list of current and past medical problems. Next, the strategies for addressing each problem, including diagnostic, therapeutic, and patient education plans. Progress notes in a POMR are documented using the SOAP method.