Procedure
Record a dose
Record a medication dose you have given, confirm the patient, drug and time, and mark the task done so the record stays current.
You record a medication dose the moment you give it. Forge carries the order, and marking the dose keeps the record current for the next nurse and the clinician.
You reach a dose from your due list or from the patient's orders. Recording it confirms the five rights and marks the task done, so the record and the due list stay current.
Record the dose
- 1
Open the dose
Find the dose on your due list or in the patient's orders, and open it. The administration panel opens with the patient identity banner above it.
- 2
Confirm the patient
Read the banner: the name, the ward, and the banner's own colour. The same patient always shows the same colour, so an unexpected colour warns you a different chart is open. If it looks wrong, stop and check.
- 3
Confirm the drug, dose, route and time
The panel shows the current order. Verify the five rights against the patient in front of you.
- 4
Complete any extra check
A controlled drug asks for a witness, and a high-alert drug asks for a second check. Enter these when the panel asks. A routine dose stays a single tap.
- 5
Mark it given
Press Given. The dose clears from the due list, and the record shows it given, with your name and the time. If the write times out, the dose stays due, so press Given again.
- 6
Record another outcome
If the dose was not given, choose what happened. A clinical instruction not to give it is Held. A patient who declines is Refused. A drug that has not reached the ward is Unavailable. Pick the reason from the list, and the record keeps the outcome and the reason together. A dose that reaches its due time with no outcome recorded stands as Missed, which the record sets rather than you.
A dose stands as given
Every dose names the nurse who gave it and the moment it was given. A recorded dose stands as a fixed entry, and a correction is a new entry beside it, so the trail stays whole.
Where the charge lands
A medication is charged when pharmacy issues it, per strip or vial, rather than per dose. Recording a dose keeps the clinical record current and leaves the account to Vault.
Common questions
The banner colour looks wrong. What do I do?
Stop. The banner colour comes from the patient, so an unexpected colour means a different record is open. Close it and open the right patient. Read if you charted the wrong patient.
Why do some doses ask for a witness or a second check?
A controlled drug asks for a witness, and a high-alert drug asks for a second check. The extra checks appear only where the drug calls for them, so a routine dose stays quick.
The patient refuses the dose. What do I record?
Record it as Refused, with the reason. A refusal is the patient's decision and stays on the record as one. A dose not given on a clinical instruction is Held, which is a different entry.
Can I correct a dose I recorded by mistake?
Mark the entry Given in error, then record what happened as a new entry. The original stays on the record, marked, and the correction sits beside it.
Hand over cleanly at the end of your shift in hand over a shift, and read how medication orders run from placement to the bedside.