Medication Administration Record
25
Osman, Faadumo
Unit: Med-Surg 4W
Dx: Acute confusion
Allergies: NKDA
Medication Administration Record
Medication
Scheduled medications
0.9% Sodium Chloride (NS)
Rate: 125 ml/hr · Route: IV · Continuous
Document your rationale for holding:
Lisinopril (Zestril)
ACE Inhibitor
Dose: 10 mg · Route: PO · Frequency: Daily
Home medication; continued on admission
Document your rationale for holding:
Amlodipine (Norvasc)
Calcium Channel Blocker
Dose: 5 mg · Route: PO · Frequency: Daily
Home medication; continued on admission
Document your rationale for holding:
Furosemide (Lasix)
Loop Diuretic
Dose: 40 mg · Route: PO · Frequency: Daily
Home medication; continued on admission
Document your rationale for holding:
Ceftriaxone (Rocephin)
Third-generation Cephalosporin
Dose: 1 g · Route: IV · Frequency: q24h
New order; empiric antibiotic
Document your rationale for holding:
Good clinical judgment!
You reviewed the medication orders in context of the full clinical picture, not just the schedule. The case continues.
Don't forget to close the loop
Holding a medication is a clinical decision, not the end of one. Each held medication needs to be communicated to the provider with your reasoning documented, so the team can take note and follow up. The medications held in this scenario were:
- Lisinopril (Zestril)
- Amlodipine (Norvasc)
- Furosemide (Lasix)
- Ceftriaxone (Rocephin)
Take card #19
