Alabama Administrative Code
Title 610 - ALABAMA BOARD OF NURSING
Chapter 610-X-14 - MEDICATION ASSISTANT, CERTIFIED (MAC)
Section 610-X-14-.15 - Documentation Standards
Universal Citation: AL Admin Code R 610-X-14-.15
Current through Register Vol. 42, No. 11, August 30, 2024
(1) The standards for documentation of medication assistants, certified provided to patients by MACs are based on principles of documentation, regardless of the documentation format.
(2) Documentation of nursing care shall be:
(a)
Legible.
(b) Accurate.
(c) Complete. Complete documentation includes
reporting and documenting on appropriate records a patient's status, including
signs and symptoms, responses, treatments, medications, communication of
pertinent information to other health team members, and unusual occurrences
involving the patient. A signature of the writer, whether electronic or
written, is required in order for the documentation to be considered
complete.
(d) Timely.
1. Charted at the time or after the care, to
include medications. Charting prior to care being provided, including
medications, violates principles of documentation.
2. Documentation of medications given that is
not in the sequence of the time the care was provided shall be recorded as a
"late entry," including a date and time the late entry was made, as well as the
date and time the care was provided.
(e) A mistaken entry in the record by a MAC
shall be corrected by a method that does not obliterate, white-out, or destroy
the entry.
(f) Corrections to a
record by a MAC shall include the name or initials of the individual making the
correction.
Author: Alabama Board of Nursing
Statutory Authority: Code of Ala. 1975, § 34-21-2.1.
Disclaimer: These regulations may not be the most recent version. Alabama may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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