THE PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICATION ADMINISTRATION TRAINING PROGRAM STUDENT WRITTEN DOCUMENTATION EXAMINATION

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1 Name Date THE PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICATION ADMINISTRATION TRAINING PROGRAM STUDENT WRITTEN DOCUMENTATION EXAMINATION PART 1: PHYSICIAN PRESCRIPTION/PHARMACY LABEL COMPARISON Instructions: Below you will find three pairs of prescriptions from a PCP and their corresponding pharmacy labels. Identify the information that is different between each prescription and its corresponding pharmacy label. Circle that information on the label. 1. PHYSICIAN PRESCRIPTION Tim Barn, MD Neurologic Associates 456 Main Street Patient Name: Melinda Sullivan Date: January 5, 2004 Patient Address: RX Mysoline 200 mg SIG 2 tablets by mouth four times daily for seizures Dispense # 180 Refill _ 3 times Physician Signature: Tim Barn License #: MD Q Physician Name: Tim Barn DEA #: PHARMACY LABEL /25/2000 RX Date filled: 01/05/ tablets by mouth three times a day for seizures. Carbemazepine 200 mg QTY: 120 QRS Drugs, Inc. Refills: 3 Burns, Thomas MD Drug expiration: 10/15/2009 JULY 2012 Page 1 of 8

2 2. PHYSICIAN PRESCRIPTION Tim Barn, MD Neurologic Associates 456 Main Street Patient Name: Melissa Sulliman Date: January 5, 2004 Patient Address: RX Clonipin 0.1 mg SIG Daily: 1 tablet by mouth four times for hypertonia Dispense # 245 Refill _ 3 times Physician Signature: Tim Barn License #: MD Q Physician Name: Tim Barn DEA #: PHARMACY LABEL /25/2000 RX Date filled: 01/06/ Take 2 tablets four times a day by mouth for hypertension. Clonidine 0.1 mg QTY: 120 QRS Drugs, Inc. Refills: 3 Barn, Tim MD Drug expiration: 10/15/2009 JULY 2012 Page 2 of 8

3 3. PHYSICIAN PRESCRIPTION David Griffin, MD Gastrointestinal Associates 456 Main Street, Suite Patient Name: Date: January 5, 2004 Patient Address: RX Lansoprazole SIG 30 mg rectally before eating once daily for erosive esophagitis Dispense 2 months Refill _ 3 times Physician Signature: David Griffin License #: MD Q Physician Name: David Griffin DEA #: PHARMACY LABEL /25/2000 RX Date filled: 01/06/ Give 2 tablets by mouth once daily prior to eating for erosive esophagitis Prevacid 15 mg QTY: 150 QRS Drugs, Inc. Refills: 2 Barn, Tim MD Drug expiration: 10/15/2009 JULY 2012 Page 3 of 8

4 JULY 2012 Page 4 of 8

5 PART 2: MEDICATION ADMINISTRATION RECORD Instructions: Create a new MAR and document the following entries. Document the following on the medication Administration Record (MAR) Assume that the following standard times apply: once a day occurs at 8 am, twice a day at 8 am and 10 pm, three times a day at 8 am, 4 pm, and 10 pm, and four times a day at 8 am, 12 noon, 4 pm, and 10 pm. a. Enter the information using pharmacy label in 1. b. Enter the information using pharmacy label in 2. c. Enter the information using pharmacy label in 3. d. A typical medication administration for clonidine on July 3 rd at 4 pm. e. A missed dose of Prevacid on July 7 th. f. A late administration of Prevacid given at 8 pm on July 7 th. g. Discontinue the Carbemazepine on July 9 th after the 4 PM dose. JULY 2012 Page 5 of 8

6 PHARMACY LABEL /25/2000 RX Date filled: 01/05/ tablets by mouth three times a day for seizures. Carbemazepine 200 mg QTY: 120 QRS Drugs, Inc. Refills: 3 Burns, Thomas MD Drug expiration: 10/15/2009 PHARMACY LABEL /25/2000 RX Date filled: 01/06/ Take 2 tablets four times a day by mouth for hypertension. Clonidine 0.1 mg QTY: 120 QRS Drugs, Inc. Refills: 3 Barn, Tim MD Drug expiration: 10/15/2009 PHARMACY LABEL /25/2000 RX Date filled: 01/06/ Give 2 tablets by mouth once daily prior to eating for erosive esophagitis Prevacid 15 mg QTY: 150 QRS Drugs, Inc. Refills: 2 Barn, Tim MD Drug expiration: 10/15/2009 JULY 2012 Page 6 of 8

7 MEDICATION ADMINISTRATION RECORD (MAR)-FRONT MEDICATION HOUR Dates of administration from: to PHYSICIAN(S): ALLERGIES: UNKNOWN DIAGNOSES: NAME: DOB ID NUMBER: JULY 2012 Page 7 of 8

8 MEDICATION ADMINISTRATION RECORD (MAR)-BACK: DATE TIME GIVEN MEDICATION & DOSE ROUTE REASON RESPONSE INITIALS INI- TIALS ADMINISTRATOR S SIGNATURE INI- TIALS ADMINISTRATOR S SIGNATURE JULY 2012 Page 8 of 8