Age Care certIV

legislation, regulations, codes of practice and workplace policies, including:

· commonwealth and state/territory legislation regarding the administration of medication including the Drugs and Poisons Act

· Disability Services Acts (commonwealth and state)

· Aged Care Act

· duty of care

· work health and safety

· standard and additional infection control precautions

roles and responsibilities of those involved in medication administration and limitations of own role in only providing assistance

basic medication terminology

forms of medication, and how they are handled, administered and stored, including:

· capsules

· drops

· inhalants

· liquids

· lotions and creams

· ointments

· patches

· powders

· tablets

· wafers

· pessay

· suppository

characteristics of at least 10 commonly used medications in the area of work, including prescribed and over the counter medications, including:

· purpose

· expected effects and potential reactions

· contraindications for use

· consequences of incorrect use

· storage requirements

· disposal requirements

documentation requirements for the administration of medication, including:

· purpose

· potential impacts of errors and reasons for error medication charts, their role and procedures for use

For all documentation on the performance criteria and assessment requirements of the unit HLTHPS006 Assist clients with medication, please refer to the training.gov.au website with this link: https://training.gov.au/Training/Details/HLTHPS006.

Students: Please fill out this cover sheet clearly and accurately for this task.

STUDENT DECLARATION

I, , certify that the statements I have attested above have been made in a good faith, are true and correct. To the best of my knowledge and belief, these tasks are my own work.

Student Signature: …………………………… Date: ............... /................./...................................

ASSESSOR FEEDBACK (Assessment Task 1 to Task 2)

Assessors: Please return this cover sheet to the student with assessment results and feedback.

Assessor signature: Date:

ASSESSOR FEEDBACK (Assessment Task 3)

Assessor signature: Date:

ASSESSOR FEEDBACK (Assessment Task 1 to Task 2)

Assessors: Please return this cover sheet to the student with assessment results and feedback.

Assessor signature: Date:

ASSESSOR FEEDBACK (Assessment Task 3)

Assessor signature: Date:

ASSESSOR FEEDBACK (Assessment Task 1 to Task 2)

Assessors: Please return this cover sheet to the student with assessment results and feedback.

Assessor signature: Date:

ASSESSOR FEEDBACK (Assessment Task 3)

Assessor signature: Date:

ASSESSOR DECLARATION

STUDENT FEEDBACK AND ASSESSMENT APPEALS

You can make an appeal about an assessment decision by putting it in writing and sending it to us. Refer to your Student Handbook for more information about our appeals process.

I have received my assessment result and I am satisfied with the given feedback for this assessment.

I am not satisfied about my result and I would like to appeal regarding my result.

Student Signature: …………………………… Date: ......... /.........../..................

What do I need in order to complete this assessment?

Access to textbooks and other learning materials.

Access to a computer and the Internet (if you prefer to type your answers).

When do I do this task?

You will do this task in the classroom or as homework – your assessor will advise.

what do I need to do if I get something wrong?

If your assessor marks any of your answers as incorrect, they will talk to you about resubmission. You will need to do one of the following:

Answer the questions that were incorrect in writing.

Answer the questions that were incorrect verbally.

Instructions to students:

Provide answers for each of the following questions.

Question 1

What is the name of the legislation (Acts and Regulations) that covers the administration of medication in your state/territory? How does this relate to you assisting clients with medication? (25 - 50 words)

What is the name of the Commonwealth Act that covers Aged Care in Australia?

What is the name of the Commonwealth Act that covers Disability Services in Australia

What legislation, regulations and codes of practice cover WHS procedures in your state or territory? How does this relate to you assisting clients with medication? (25 - 50 words)

Question 2

1. You have been delegated to assist with the administration of medication in your service. In one paragraph, describe your duty of care to your clients.

What legislation covers the duty of care procedures? What information does it tell you about assisting clients with medication? (25 – 50 words)

What are two work health and safety hazards that Jenny has allowed to happen in this situation?

Question 3

1. When are additional infection control precautions needed?

Is this correct – why/why not?

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Question 4

In the following table describe the characteristics of each of the medications listed.

Drug	Purpose	Expected effects	Potential reactions	Contraindications for use	Consequences of incorrect use	Storage requirements	Disposal requirements
Augmentin Duo
Zyrtec
Valium (Diazepam)
Doxepin
Aspirin (acetylsalicylic acid)
Naproxen
Panadeine forte
Captopril (ACE inhibitor
Morphine
Atorvastatin

Question 5

In the following table provide a short explanation of the medical terminology and abbreviations.

Medical term/abbreviation	Short explanation
Drug interaction
Drug of dependence
Controlled drug
Drug half life
OTC
Acute pain
Chronic pain
Topical
Aperient
Aqueous solution
Pessary
Capsule
Syrup
Transdermal patch
Nebuliser
b.i.d
q.i.d
PRN
PO
Mg

Question 6

In the following table provide a short explanation of how each form of medication is handled, administered and stored.

Form of medication	How it is handled	How it is administered	How it is stored
Capsule
Drops
Inhalant
Liquid
Lotions and creams
Ointments
Patches
Powders
Tablets
Wafers
Pessary
Suppository

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HLTHPS006 Assist Clients with Medication

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Question 7

1. What are three purposes of a client medication chart?

1.

2.

3.

What are three purposes of the client’s care plan

1.

2.

3.

Jemima was very busy today. When she did the medications round she tried her best to do everything in line with policy and procedures but she was seriously short of time. She was distracted after giving Mrs Flowers her evening medication and she forgot to record it on her medication chart.

What are three possible consequences of this?

1.

2.

3.

Question 8

Mrs Jumbleweed requires her antibiotics are regular intervals throughout the day and night. She needs to take four doses each day.

1. How many hours apart must each dose be administered?

Mr Blenkinsop is prescribed 2grams of medication three times a day. His medication comes in tablets of 500mg.

How many tablets does Mr Blenkinsop take each day?

Miss Higginbottom is prescribed a cream that must be mixed in a ratio of 1:4 with water.

If 20 ml of cream is to be applied, how much water should this be mixed with?

Mr Billingsworth-Smyth has been prescribed a liquid medication. He is to have 10ml twice a day. The bottle holds 100ml.

How many days’ worth of medication does he have?

ASSESSMENT TASK 2: ROLE PLAYS

Task Summary: Complete each role-play to assist clients with medication.

What do I need in order to complete this assessment?

· Client care plans (provided)

· Client medical chart (provided)

· Simulated medication labelled with client name, expiry dates and dosage instructions:

Simulated tablets (in dose administration aid; for example, dosette box)

Simulated liquid oral medication

Simulated topical cream

Simulated ear drops

Simulated eye drops

Simulated nose drops.

· Dummy or doll that can be used for applying eye drops, ear drops and nasal drops

· Medication administration equipment, including:

Measuring spoons

Medicine cups

Container for used equipment

Tumblers and water pitcher

Container for contaminated or out-of-date medication.

· PPE – disposable gloves, face mask and apron

· Bins for clinical waste, ordinary waste and pharmacy waste

· Facilities to clean and store medication containers and administration aids

· Simulated lockable storage areas for medications (including refrigerated and non-refrigerated)

· Role play participants to play the roles of three clients and a supervisor

· Policies and procedures for assisting with medication (provided) – residential aged care and HACC

· Box of tissues for eye drops, ear drops and a teary client.

When do I do this task?

· This task is to be completed in the classroom

· This task must be satisfactorily completed prior to attempting Assessment Task 3, Part B

what do I need to do if I get something wrong?

If your assessor sees that you have not shown appropriate skills or knowledge, they will give you some feedback and you will need to do the specific task again.

Instructions:

You must complete the following three role plays.

Role Play 1 – John Williams – Home and Community Care setting

Role Play 2 – Angelina Lentini – Residential Aged Care setting

Role Play 3 – Sunny Macklin – Residential Aged Care setting.

You will be required to assist each of the clients (your role play participants) with their medications. You will be provided with:

medication policy for each care setting

a care plan for each client

simulated medication

medication administration equipment

medication administration chart.

Your assessor will play the role of the medications supervisor.

Your assessor may ask you questions as you proceed through each role play.

To prepare for these role plays you must read the sample policy and procedures for medication management that has been provided for each role play.

The table below gives further information about what you need to show during each role play.

At the end of each role play you will find a table that outlines what your assessor will be assessing you against during the interaction.

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HLTHPS006 Assist Clients with Medication

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Role play 1

Your client is Mr John Joseph Williams. John receives services from the Greater Lillipudlian HACC service in his home Monday to Friday. John receives personal care support, including assistance with the administration of medication. John’s care plan and medication chart follow. It is currently 8am on 18 December 2015.

Assist John Williams with the administration of his medication.

Details of Client
Name of Client:  John Joseph WILLIAMS  Address: 15 Woodlands Circuit, BISHOPS HEAD, VIC HACC Service: Greater Lillipudlian HACC service Supervisor in Charge: Mary Supervisor
DOB: 1 August 1950                 AGE: 65                                            Male/Female: M  Country of birth: Australia        Ethnicity: Australian                                     Marital Status: Single Religion: None                         Spiritual Preference: None
Personal Care Needs (comment on the assistance and support required)
Dressing: Requires assistance Toiletry: Requires assistance Bathing: Requires assistance Oral hygiene: Requires assistance Hydration and nutrition: Does not require assistance with eating and drinking Maintenance of skin integrity: Subject to pressure sores Mobility and transfer: Uses mobility aid (wheeled walker) Can transfer self. May need some assistance occasionally Medication: Able to self-medicate. May need assistance to take tablets and apply eye drops	Pain: Frequently has severe pain in joints Rest and sleep: Good Respiratory issues: None Dressings: None Catheter care: None Application of prostheses: None Assistance with anti-thrombotic stockings: No Simple eye care: Subject to dry eyes – may require eye drops
Personal preferences for personal care: Requires some assistance with personal care but likes to do anything he can for himself.  Any issues with fear, embarrassment or humiliation for support provided? No.  Any identifiable risks for support provided? Manual handling risk if client needs assistance with transfer
Aid or equipment required
Wheelchair: N/A Wheelie Walker: yes Walking Stick: N/A Other Mobility aids: N/A Lifting and transferring aids:   N/A	Breathing devices: N/A Continence aids: N/A Audio/visual aids: Wears glasses and a hearing aid Feeding aids:  N/A

Health and well being
Height: 5”11                  Weight: 85kg                Blood Pressure:                       110/80
Does the client suffer from any of the following: Any Allergies (please list):  Anxiety issues Arthritis Yes Asthma Behavioural Conditions: Can get frustrated and angry Birth Defects Cancer Chronic Disease (please specify) Chronic Illness (please specify) Diabetes	Dementia Depression Yes Hearing Yes Incontinence Infections Mental Health/Illness issues Oral Health Parkinson’s Disease Sexual issues Sleep Conditions Sight Stroke
What is the general condition of the client’s health: Physical:  Arthritis causes pain and frailty. Client can generally transfer self but may need assistance if pain and stiffness is too great. Emotional:  Occasionally becomes frustrated and angry. Is not happy that he needs to have home care services. Psychological: John suffers from depression – treated with medication and counselling.
Are there any issues that may have impacted the client’s health:  Disability: Arthritis causing loss of movement/function, pain and stiffness. Illness: Neglect: Abuse: Other:
Are there any issues that could have impacted on the client’s well-being - both emotional and psychological? (eg stress, anxiety, isolation, depression) Can get frustrated and angry.  Annoyed that he needs personal care support when he is only 65
Does the client suffer from pain (if so please specify)  yes – arthritis pain

MEDICATION CHART
Details of Client
Name of Client:  John Joseph WILLIAMS  Address: 15 Woodlands Circuit, BISHOPS HEAD, VIC HACC service: Greater Lillipudlian HACC service Supervisor in Charge:  Mary Supervisor
DOB: 1 August 1950                 AGE: 65                                            Male/Female: M  Country of birth: Australia        Ethnicity: Australian                                 Marital Status: Single Religion: None                         Spiritual Preference: None
Doctor’s name: Dr Son Good                 Phone: (09) 9998-9998              Email: [email protected] Pharmacy name: New Greens Pharmacy   Phone: (09) 9998-9787      Email: [email protected]
Regular continuous	Dose and route	Date initiated	Dr sign/date
Ibuprofen	400mg three times per day – PO	15 December 2015	HR Good 13/12/2015
Zoloft	50mg once per day – PO	15 December 2015	HR Good 13/12/2015
When required (PRN)	Dose and route	Date initiated	Dr sign/date
Luxyal (eye drops)	2 drops to each eye – conjunctival	11 November 2015	HR Good 13/12/2015
Drug	Classification	Condition under treatment
Ibuprofen	NSAID	Osteo-arthritis
Zoloft	SSRI	Depression
Luxyal	Eye drops	Dry eyes

MEDICATION RECORD – STUDENT TO COMPLETE
Regular continuous medication:
Ibuprofen 400mg	Date	16/12	16/12	16/12	17/12	17/12	17/12
	Time	08.00am	12.30pm	5.00pm	8.00am	12.30pm	Refused by client
Dose	Frequency	Dose	400mg	400mg	400mg	400mg	400mg
400mg	tds with food	Route	O	O	O	O	O
	Signed	MJ	MJ	MJ	MJ	MJ
Zoloft 50mg	Date	16/12	17/12
	Time	08.00am	8.05am
Dose	Frequency	Dose	50mg	25mg
50mg	Daily in morning	Route	O	O
	Signed	MJ	MJ
Luxyal sterile eye drops 10ml	Date	16/12
	Time	3.00pm
Dose	Frequency	Dose	2 drops
2 drops to each eye	PRN	Route	conjunc
	Signed	MJ
MEDICATION ASSISTANCE REQUIRED
MEDICATION ASSISTANCE REQUIRED Client is able and approved to self-medicate. Due to pain and stiffness caused by arthritis, client may need some assistance with taking oral medication. Client requires eye drops PRN for dry eyes. John will require assistance to apply these.
MEDICATION OBSERVATIONS
ANY CHANGES IN PHYSICAL OR BEHAVIOURAL STATE OF CLIENT NOTICED IN OBSERVATION PRIOR TO MEDICATION: REPORTED TO SUPERVISOR? YES NO N/A
ANY CHANGES IN MEDICATION ADMINISTRATION SUPPORT REQUIRED REPORTED TO SUPERVISOR? YES NO N/A
PLEASE LIST ANY COMMENTS MADE BY THE CLIENT ON THEIR OWN HEALTH AND WELL BEING: REPORTED TO SUPERVISOR? YES NO N/A
OBSERVATION AFTER MEDICATION ADMINISTRATION: REPORTED TO SUPERVISOR? YES NO N/A
Name of student: ______________________________________ Signed: _______________________________________________ Date: _________________________________________________

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Sample policy and procedure for medication administration in Home and Community Care setting

(This sample policy and procedure is for the purpose of assessment only and should only be used for role play purposes.)

This sample policy and procedure is for use of the fictitious Greater Lillipudlian HACC Service.

Preamble

The appropriate use of medication can treat disease and/or control symptoms and thereby improve health and comfort. Clients requiring support in the administration of medication in their homes through the HACC service will be provided with this support subject to this document.

Policy

Greater Lillipudlian HACC Service, will take every step to ensure that staff administer or supervise medication safely and correctly according to Regulatory Guidelines.

Processes to be followed	Comments
1. Ensure the following processes reflect the vision, mission and philosophy of care of the Greater Lillipudlian HACC Service and the National Standards.
2. Prescribed administration and supervision of medication management must comply with regulatory requirements.	At all times
3. Clients should be encouraged to manage their own medicines, including procurement, storage, administration and disposal for as long as they are able to do this with safety.	This includes prescription, non-prescription medications and complementary health care products.
4. Care workers should encourage clients and if necessary their carers, to discuss medications with their health care professional and pharmacist.
5. If a client and their carer is unable to administer their own medication, a formal assessment process will be undertaken by suitably qualified health care professional.
6. If a care staff member finds that a client is no longer able to administer their own medications, they must report to their supervisor so that an assessment process can be undertaken.
7. Details of support required for client administration of medication must be included on a medication chart. This chart will include: Personal details of the client Photo identification Assistance required by client to administer and store medication Any potential problems. Strategies to ensure medications are being administered and stored correctly: Name and contact number of medical practitioner Name and contact number of pharmacy Name of regular continuous medication, dose and route, date initiated and doctor’s signature Name of PRN medication, dose and route, date initiated and doctor’s signature Classification of medication and condition under treatment Medication record – date, time, route and dose of each medication Medication observations Changes required to administration support
8. Prior to administering or supervising any medication including liquids and PRN medication, the following should occur: Must be recorded on the medication chart by the treating medical practitioner RN Div 1 must check all medicines against the order: · Right client · Right dose · Right route · Right frequency · Right time Medication orders must be written in a generic and legible form. Care staff supervising and administering medication must check prior to handing over the Dosage Administration Aid to the client: · Right DAA pack · DAA pack is intact · Right client (check name and photo ID) · Right time · Right route
9. Care workers must be appropriately trained before assisting clients with the administration of medication in accordance with legislative requirements.
10. Care workers must follow organisational policies and procedures when assisting clients with administration of medication
11. Care workers must be provided with clear instructions on the steps the worker will take to support their client and/or their carer.
12. Care workers must only provide services for which they have received training and demonstrated competency.
13. Care workers must not make any decisions about whether a medication should be administered. These must be referred to their supervisor.
14. Alteration of the formulation of oral medications (eg breaking or crushing tablets to assist administration) should be avoided wherever possible. Where alteration of the formulation is necessary, this must not be done without instruction from the prescriber or other relevant health care professional.
15. Clients and/or their carers should be encouraged to store their medications correctly to safeguard the quality of the medication and the safety of clients, children and family members. Clients should be reminded of the importance of storing their medications in line with the instructions on the label.
16. Medications must be stored where possible in original container or dosage administration aid at the correct temperature.
17. Clients may need assistance in storing medications safely – for example where these need to be kept out of the reach of children or where the client is unable to read or understand the medicine label.
18. Where there is a major risk of accidental overdose (eg caused by confusion or dementia), medications should be kept out of sight and reach of the client, but accessible to carers or support workers responsible for administration.
19. Clients and/or their carers should be encouraged to follow recommended practices for the disposal of out of date or unwanted medications. Where support is required for the care worker for the disposal of medication this must only be done with the consent of the client and/or their carer.
20. Any discrepancies or incidents related to medication administration must be reported on an incident report and notified to the: • Treating Medical Practitioner. • Pharmacist. • Client and/or carer Unresolved discrepancies must also be notified to the Secretary of the Department of Human Services.	Must be done immediately
21. All drug incidents must be investigated.	By organisation management delegated to do so

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Assessment Task 2: Role play 1 – John Joseph Williams – HACC Setting
Your assessor will be looking to see that you	Comments	Attempt 1 Yes/No Date:	Attempt 2 Yes/No Date:	Attempt 3 Yes/No Date:
Access and interpret policies and procedures relating to providing assistance to clients with medication
Follow infection control principles
Check and confirm that all equipment and medications to be administered are available, ready for distribution and up to date
Confirm with your supervisor that you are authorised to proceed with assisting clients with their medication
Access and interpret client care plans/medication chart relating to medication needs?
Clarify with the supervisor the assistance that will be required by each client?
Clarify the level of supervision that the client will require to check whether they have correctly self-administered their medication?
Correctly identify and greet each client?
Correctly explain to the client the medication they are to receive and prepare them for administration of the medication?
Check individual client medications against medication chart
Identify the client’s current physical and behavioural condition and recognise and report any circumstances where administration of medication should not proceed
Provide medication to client and prompt them to take/accept medication at the correct time?
Prepare the medications and support the clients’ self administration according to procedures and the individual care plan ensuring that: The Right medication is given at the Right time, to the Right person, in the Right amount, via the Right route
Assist and observe each client when taking medication and confirm with them that ingestion or completion is complete
Follow correct procedures if medication is not administered or absorbed, or if there are any other inconsistencies
Identify any contaminated or out-of-date medication and follow the correct procedures?
Accurately complete medication records
Observe client for changes in condition following medication follow correct procedures
Discard other waste products according to requirements
Clean and correctly store used and unused medication containers, administration aids and supply of medications

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HLTHPS006 Assist Clients with Medication

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Role play 2

Your client is Mrs Angelina Lentini. Angelina lives at the New Greens Aged Care residential facility. Angelina’s care plan and medication chart follow. It is currently 7pm on 18 December 2015.

Assist Angelina Lentini with the administration of her medication.

Details of Client
Name of Client:  Angelina LENTINI  Room number: 9  Name of Facility:  New Greens Aged Care  Supervisor in Charge:  Mary Supervisor
DOB: 1 August 1915                 AGE: 100         Male/Female: F Country of birth: Italy        Ethnicity: Italian                               Marital Status: Widowed Religion: Catholic
Personal Care Needs (comment on the assistance and support required)
Dressing: Requires assistance Toiletry: Requires assistance Bathing: Requires assistance Oral hygiene: Requires assistance Hydration and nutrition: Does not require assistance with eating and drinking Maintenance of skin integrity: Eczema Mobility and transfer: Uses mobility aid (wheeled walker) Can transfer self. May need some assistance Medication: Able to self-medicate. May need assistance to take tablets. Needs assistance to apply cream.	Pain: At times has severe headaches Rest and sleep: Frequent insomnia Respiratory issues: None Dressings: None Catheter care: None Application of prostheses: None Assistance with anti-thrombotic stockings: No Support with breathing tubes: None Simple eye care: Subject to dry eyes – may require eye drops
Personal preferences for personal care: Requires some assistance with personal care and likes to be helped by care staff.  Any issues with fear, embarrassment or humiliation for support provided? No.  Any identifiable risks for support provided? Manual handling risk if client needs assistance with transfer.
Aid or equipment required
Wheelchair: N/A Wheelie Walker: yes Walking Stick: N/A Other Mobility aids: N/A Lifting and transferring aids:   N/A Beds: Standard facility equipment	Breathing devices: N/A Continence aids: N/A Audio/visual aids: Wears glasses and a hearing aid Feeding aids:  N/A
Health and well being
Height: 5”3                 Weight: 74 kg                Blood Pressure:                       140/90
Does the client suffer from any of the following: Any Allergies (please list):  Anxiety issues Arthritis Yes Asthma Behavioural Conditions Can get frustrated and angry Birth Defects Cancer Chronic Disease (please specify) Chronic Illness (please specify) Diabetes	Dementia Depression No Hearing Yes Incontinence Infections Mental Health/Illness issues Oral Health Parkinson’s Disease Sexual issues Sleep Conditions Sight Stroke
What is the general condition of the client’s health: Physical:  Angelina is overweight and has high blood pressure. She has eczema on her arms. She is 100 years old and quite frail. Emotional:  Usually very happy but somewhat frustrated by her frailty and her itchiness. Psychological:
Are there any issues that may have impacted the client’s health:  Disability: Illness: High blood pressure Neglect Abuse Other
Are there any issues that could have impacted on the client’s well-being - both emotional and psychological? (eg stress, anxiety, isolation, depression) N/A
Does the client suffer from pain (if so please specify) No pain but eczema is very itchy.

MEDICATION CHART
Details of Client
Name of Client:  Angelina LENTINI  Room number: 9  Name of Facility:  New Greens Aged Care  Supervisor in Charge:  Mary Supervisor
DOB: 1 August 1915               AGE: 100 Male/Female: F Country of birth: Italy        Ethnicity: Italian Marital Status: Widowed Religion: Catholic
Doctor’s name: Dr Son Good                 Phone: (09) 9998-9998            Email: [email protected] Pharmacy name: New Greens Pharmacy    Phone: (09) 9998-9787       Email: [email protected]
Regular continuous	Dose and route	Date initiated	Dr sign/date
Verapamil 40mg	40mg tds with food – oral	15 December 2015	HR Good 13/12/2015
Ego Dermaid 1% cream	Apply thin layer to affected skin bid – topical	15 December 2015	HR Good 13/12/2015
When required (PRN)	Dose and route	Date initiated	Dr sign/date
Polaramine (timed release preparation)	6mg at bedtime - oral	11 November 2015	HR Good 13/12/2015
Drug	Classification	Condition under treatment
Verapamil 40mg	Calcium channel blocker	Reduce high blood pressure
Ego Dermaid 1% cream	Topical corticosteroid cream	Eczema
Polaramine (timed release preparation)	Antihistamine	Itch as a result of eczema

MEDICATION RECORD – STUDENT TO COMPLETE
Regular continuous medication:
Verapamil 40mg	Date	17/12	17/12	17/12	18/12	18/12
	Time	08.00am	12.30pm	5.00pm	8.00am	12.30pm
Dose	Frequency	Dose	40mg	40mg	40mg	40mg	40mg
400mg	tds with food	Route	O	O	O	O	O
	Signed	MJ	MJ	MJ	MJ	MJ
Ego Dermaid 1% cream	Date	17/12	17/12	18/12
	Time	08.00am	7.00pm	08.00am
Dose	Frequency	Dose	Thin layer	Thin layer	Thin layer
50mg	Daily in morning	Route	Top	Top	Top
	Signed	MJ	MJ	MJ
Polaramine	Date
	Time
Dose	Frequency	Dose
6mg	PRN	Route
	Signed
MEDICATION ASSISTANCE REQUIRED
MEDICATION ASSISTANCE REQUIRED Client is able and approved to self-medicate. Ms Lentini likes to be assisted. Client requires Ego Dermaid to be rubbed on all parts of her eczema affected skin. Client may request Polaramine if the eczema is itchy. This also helps her to sleep.
MEDICATION OBSERVATIONS
ANY CHANGES IN PHYSICAL OR BEHAVIOURAL STATE OF CLIENT NOTICED IN OBSERVATION PRIOR TO MEDICATION: REPORTED TO SUPERVISOR? YES NO N/A
ANY CHANGES IN MEDICATION ADMINISTRATION SUPPORT REQUIRED REPORTED TO SUPERVISOR? YES NO N/A
PLEASE LIST ANY COMMENTS MADE BY THE CLIENT ON THEIR OWN HEALTH AND WELL BEING: REPORTED TO SUPERVISOR? YES NO N/A
OBSERVATION AFTER MEDICATION ADMINISTRATION: REPORTED TO SUPERVISOR? YES NO N/A
SUPERVISOR NOTIFIED:    Y   N
Name of Student: ______________________________________ Signed: _______________________________________________ Date: _________________________________________________

Sample policy and procedure for medication management in Residential Aged Care facility.

Reference Outcome – Residents’ medication is managed safely and correctly.

(This sample policy and procedure has been adapted from the Integrated Best Practice Model for Medication Management in Residential Aged Care Facilities developed by the Australian Pharmaceutical Advisory Council. Acknowledgment for use to TQM Training Services).

(This sample policy and procedure is for the purpose of assessment only and should only be used for role play purposes.)

This sample policy and procedure is for use of the fictitious New Greens Residential Facility.

Preamble

The appropriate use of medication can treat disease and/or control symptoms and thereby improve health and comfort. Medications will be safely administered and stored in a manner that protects residents and staff in accordance with relevant legislative requirements.

Policy

[RACS name] will take every step to ensure that staff administer or supervise medication safely and correctly according to Regulatory Guidelines.

Processes to be followed	By Whom	By When	Relevant Documents
1. Ensure the following processes reflect the vision, mission and philosophy of care of the (RACS name) and the Commonwealth Standards.	All staff	On going	Policy
2. Prescribed administration and supervision of medication management must comply with regulatory requirements.	Treating medical practitioner Pharmacist Care staff supervising and administering medication	At all times	Policy Pharmacy Policy
3. Prior to administering or supervising all medication including liquids and PRN medication, the following should occur: • Must be recorded on the medication chart by the treating medical practitioner. • RN Div 1 must check all medicines against the order: - To the right resident. - At the right dose. - By the right route. - By the right frequency. - At the right time. • Medication orders must be written in a generic and legible form. • Care staff supervising and administering medication must check prior to handing over the Dosage Administration Aid (DAA) to the resident: - The right DAA pack. - The Dosage Administration Aid (DAA) is intact. - To the right resident- check the name and the photo. - At the right time. - By the right route.	Treating medical practitioner RN Div 1 RN Div 2 endorsed Care staff supervising and administering medication	Within 48 hours of admission Prior to administering medication Medication review- every 8 weeks	Policy Medication Charts Client Progress Notes Pharmacy Policy Prescriptions
4. For a new resident the treating doctors notes, incorporating medication, should be relied on in the first instance, or a phone order taken by a nurse.	Treating medical practitioner Nurse in charge	Within 48 hours	Medication Charts
5. Resident’s treating medical practitioner will be requested to review medications in consultation with the resident and/or their representative.	Treating medical practitioner RN Div 1 Care staff supervising and administering medication	Within 48 hours of admission Prior to administering medication Medication review- every 8 weeks	Policy Medication Charts Client Progress Notes Pharmacy Policy Prescriptions
6. A registered nurse assessing the resident’s medication requirements must contact the relevant doctor to examine the resident and determine the medication requirement prior to the expiration of the existing written orders.	Doctor RN Div 1 Nurse in charge Resident	On every occasion	Nurses Act Drugs Poisons and Controlled Substances Act Aged Care Act 1997
7. When administering medication the RN Div 1 who has delegated responsibility must use their judgment in determining the appropriateness of the medication. • Staff will contact the treating medical practitioner if there is any query regarding the medication BEFORE it is administered. • Staff (RN Div 2 endorsed) administering medication should direct their concerns to: - RN Div 1 on duty. - Pharmacy. - Treating Medical Practitioner. • Any variation to orders must be recorded in the Total Care Progress Notes. Staff supervising medication should direct their concerns to: - RN Div 1 on duty. - Pharmacy. - Treating Medical Practitioner. • Any variation to orders must be recorded in the Total Care Progress Notes.	Treating medical practitioner RN Div 1 RN Div 2 (endorsed) Care staff supervising and administering medication	On every occasion	Medication Charts Client Care Progress Notes
8. Only RN Div 1 are allowed to initiate S2 or S3 drugs such as: • Paracetamol for aches and pains. • Liquids for indigestion e.g. Mylanta. • Preparations for constipation. If the medicines need to be administered more than once then the medical practitioner’s orders must be sought. A record of any nurse initiated drugs should be included on the resident’s medication chart.	Treating medical practitioner RN Div 1	As necessary	Policy Pharmacy Policy
9. No nurse should initiate drugs that are not on the list of nurse initiated medicines for this facility including: • Nebulisers. • PR medications. • PV medications. • Creams and Ointments. • Eye and ear drops and creams. • Mixtures.	DON Nurse in charge	At all times	Policy
10. Treating medical practitioner and pharmacist advice must be sought and documented on the medication chart if a resident requests a non-prescription substance, including homeopathic medicines, and ‘over the counter’ S2, S3 and unscheduled substances, if it is not in the above list.	Nurse in charge RN Div 1	Prior to administration
11. Care staff supervising and administering medication are NOT allowed to insert PR and PV medication.	DON Nurse in charge	At all times
12. If the resident requests PRN medicines on a regular basis: The following must occur: • Thorough Assessment. • Documentation in the resident’s Total Care Progress Notes. • The treating medical practitioner should review the medication. • After review the medical practitioner may order the medicines to be given on a more regular basis.	Treating medical practitioner RN Div 1 & 2 Care staff supervising and administering medication	As necessary	Policy Client Care Progress Notes
13. Wherever possible a RN Div 1 should receive telephone orders. It is good practice that telephone orders be taken by two nursing personnel and details recorded in the “once only administration” section at the back of the Medication Chart. Where there is no RN Div 1, request the treating medical practitioner to fax the order directly to the pharmacist. If more than one dose is to be administered, each dose is to be written separately. The treating medical practitioner will be asked to visit and review the medication and sign the order.	Treating medical practitioner Two members of staff, one must be a RN Div 1	24 to 48 hours	Policy Medication Charts Pharmacy Policy
14. Medicines must be stored in individual containers in a locked storage unit in accordance with the Drugs Poisons and Controlled Substances Regulations. All medication must be clearly labelled with the resident name. No medication is to be shared between residents. Staff are not allowed to tamper or alter contents of the resident’s original medication bottles or Dosage Administration Aid (DAA)s.	Staff administering medication Pharmacy	On all occasions	Pharmacy Policy
15. Residents who wish to manage their own medication regime: • Safe and secure storage of medication will be available. • Capability of administering own medication will be assessed. • Will be documented in the resident’s file. • Regularly monitored by staff, treating medical practitioner and pharmacist.	Treating medical practitioner Pharmacist Staff Residents	On all occasions	Drug Check List (for resident administering their own medication) Dosette Box
16. When administering or supervising self-medication: • The nursing staff must remain with the resident until the medication is seen to be swallowed. • If the resident is unable to swallow the medication a liquid alternative must be obtained by contacting the treating medical practitioner and pharmacist. • Enteric Coated Drugs are never to be crushed.	Treating medical practitioner Pharmacist Staff Residents	On all occasions	Drug Check List (for resident administering their own medication) Dosette Box
17. Medication trolleys and medication refrigerators must be locked when not in use.	Treating medical practitioner Pharmacist Staff Residents	On all occasions	Pharmacy Policy Medication Charts Total Care Progress Notes
18. Medication charts must be signed to indicate that particular medication has been administered or supervision of self-administration provided. • If medicine is not given or refused, this refusal must be documented on the Medication Chart and the resident’s Total Care Progress Notes with the relevant reasons noted. • The Doctor is to be contacted for further orders. • Time frame of contact of the doctor is depending on the medication.	Staff administering/supervising of self medication	On all occasions	Pharmacy Policy Medication Charts Total Care Progress Notes
19. All medication charts must comply with the following details: - Complete name of the resident. • Identifying photograph with the name of the resident printed clearly on the back. • Date of birth of the resident. • Allergies. • Doctor’s signature for every entry. • Route. • Strength. • Dosage. • Frequency. • Signature of the staff administering or supervising the medicines. • Relevant date, month, year. • Date of next administration of infrequent drugs. • Alternative methods of administering medications. • PRN medication.	Treating medical practitioner Pharmacist Staff administering medication	On all occasions	Pharmacy Policy Medication Charts Drugs Poisons and Controlled Substance Act. Nurses Act Medication chart audit tool
20. The pharmacy is responsible for Dosage Administration Aid (DAA) and therefore the pharmacy is requested to: • Check the medication order against the prescription. • To supply the right drug with the right strength to the right resident. • Sign the back of the Dosage Administration Aid (DAA) to confirm drugs in the pack are correct. • Do periodical audits of the medication chart.	Pharmacy	At all times	Pharmacy Policy Medication Charts
21. Discrepancies to Dosage Administration Aid (DAA) must be recorded in an Incident Report and notify pharmacy to correct discrepancies.	RN Div 1	On the receiving Dosage Administration Aid (DAA)s	Pharmacy Policy Medication Charts
22. Staff must never transcribe medication orders onto medication charts.	All staff	On every occasion Policy
23. All medication expiry dates must be checked prior to administering. • Medication with spent expiry dates will be returned to the pharmacy.	Care staff supervising and administering medication Pharmacist	On all occasions	Pharmacy Policy
24. Ceased and expiry dates medications: • Explain to the resident/family that it is best for medicines to be sent back to the pharmacy for destroying. • Document in the pharmacy return book what is returning and reason for return .	Care staff supervising and administering medication Pharmacist	On all occasions	Pharmacy Policy
25. A drug register with a balance of stock on hand is required to record transactions of Schedule 8 medicines supplied in liquid form, or when supplied in other than tamper-evident dose administration containers. It is good practice that Schedule 8 drugs are checked and signed for by two people. Recording in a drug register is not required for Schedule 8 medicines in residential aged care services when: • The medicines are supplied on prescription for a specific person; • The medications are supplied in tamper evident dose administration containers, and • The containers are labelled with administration times.	RN Div 1	On all occasions	Drugs Poisons and Controlled Substance Act Dangerous Drug Register Medication Charts Client Care Progress Notes
26. Only a Division 1 nurse may administer a drug by intravenous injection. A Division 2 (endorsed) nurse who has completed the appropriate training may administer by sub-cutaneous or intra-muscular injection. Under the NBV Code for Guidance, delivery of a drug by injection to a high care resident may not be delegated to a personal care worker.	RN Div 1	On all occasions	Medication Charts Client Care Progress Notes
27. Any discrepancies or incidents related to medication administration are written on an incident report and notified to the: • Treating Medical Practitioner. • Pharmacist. • Resident and/or representative. Unresolved discrepancies must also be notified to the Secretary of the Department of Human Services. The Secretary of the Department must also be notified of any loss, destruction or theft of records relating to Schedule 8 medicines.	Treating medical practitioner Nurse administering medication Pharmacist Resident/Representative	Immediately on all occasions	Medication Charts Medication Incident Report
28. All drug incidents will be investigated.	Director of Nursing RN Div 1 Treating medical practitioner	Immediately on all occasions	Poison and Controlled substance Act Nurses Registration Board Governing Bodies
29. Medical Advisory Committee will assess, monitor, evaluate and act to address system issues to ensure safe medication usage.	Director of Nursing Nurse in charge Treating medical practitioner	Every 12 weeks	Pharmacy Policy
30. Medication Management Practices will be supported by clinical pharmacist.	Director of Nursing Clinical pharmacist	Every 12 weeks	Policy 2.2 Audit Tools
31. Staff and residents and/or representatives will be provided with ongoing education regarding medication.	Director of Nursing Doctor Nurse in charge Pharmacist	Every 6 months	Policy 2.3
32. Areas requiring improvement of this standard will be identified through audit system as a part of the Continuous Quality Improvement process.	All care staff	As scheduled	Policy 2.1

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Assessment Task 2: Role play 2 – Mrs Angelina Lentini – Residential Aged Care
Your assessor will be looking to see that you	Comments	Attempt 1 Yes/No Date:	Attempt 2 Yes/No Date:	Attempt 3 Yes/No Date:
Access and interpret policies and procedures relating to providing assistance to clients with medication
Follow infection control principles
Check and confirm that all equipment and medications to be administered are available, ready for distribution and up to date
Confirm with your supervisor that you are authorised to proceed with assisting clients with their medication
Access and interpret client care plans/medication chart relating to medication needs?
Clarify with the supervisor the assistance that will be required by each client?
Clarify the level of supervision that the client will require to check whether they have correctly self-administered their medication?
Correctly identify and greet each client?
Correctly explain to the client the medication they are to receive and prepare them for administration of the medication?
Check individual client medications against medication chart
Identify the client’s current physical and behavioural condition and recognise and report any circumstances where administration of medication should not proceed
Provide medication to client and prompt them to take/accept medication at the correct time?
Prepare the medications and support the clients’ self administration according to procedures and the individual care plan ensuring that: The Right medication is given at the Right time, to the Right person, in the Right amount, via the Right route
Assist and observe each client when taking medication and confirm with them that ingestion or completion is complete
Follow correct procedures if medication is not administered or absorbed, or if there are any other inconsistencies
Identify any contaminated or out-of-date medication and follow the correct procedures?
Accurately complete medication records
Observe client for changes in condition following medication follow correct procedures
Discard other waste products according to requirements
Clean and correctly store used and unused medication containers, administration aids and supply of medications

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© Advance College