2.6 Documentation

When performing IV push medication administration, documentation must include the following components:

• Date/Time of administration
• Medication amount and dose
• IV site location
• Administration route and rate
• Flush solution
• Indication for medication
• Patient assessments related to medication
• Patient’s response

Many electronic health records have integrated electronic medication administration records that allow nurses to document IV push medications and pre- and post-administration assessments directly within the EMAR. If developing a written note regarding the administration, it should include the components listed above.

Sample Documentation:

11/20/20XX 1445

Patient was admitted to the cardiac floor for HF exacerbation, difficulty breathing, and weight increase of 10 pounds in the past three days. Furosemide 40 mg IV push was administered via 20-gauge catheter in the right forearm per order from Margaret Vang NP for HF exacerbation. The IV site flushed freely with appropriate blood return prior to medication administration. Furosemide was administered via slow push at 10 mg/min and followed with 5-mL saline flush at the same rate.

1745 Patient voided 600 mL clear yellow urine one hour post administration. Patient lung sounds are clear, and bilateral ankle pitting edema decreased to 1+. Patient appears comfortable. 

Gus Martinez, RN