Ask Sheila - Archive England

Sheila Scott OBE has now retired and therefore is no longer available to answer your social care questions. However, you might still find the answer you’ve been searching for down below.

05th January 2021

Can an RN update the medication administration chart at a client’s home?

If a registered nurse works for a care agency who deliver home care to clients, can they update the medication administration chart at the client’s home using a discharge summary/prescription with a new or altered dose of medications?

You don’t say if the nurse is working in the capacity of a care worker in the service user’s home. If she is working as a care worker, the answer is no. What the RN has done is called transcribing and is something that carries risk and should only be done in exceptional circumstances. The Royal College of Nursing in Medicines Management say, ‘Transcribing can be defined as the act of making an exact copy, usually in writing. Transcribing is the copying of previously prescribed medicines details to enable their administration. Organisational policies and procedures for transcribing must be underpinned by risk assessment. Such policies are clear about who can transcribe when it can be used, and the difference between transcribing and prescribing. Transcribing should not be confused with prescribing or badged as transcribing when in fact it is prescribing. Transcribing can only be used to make an exact copy of medicines that have already been prescribed, for example, patients own medicines that have been prescribed and dispensed by a pharmacy can be transcribed onto a Medicines Administration Record (MAR) chart so their administration can be recorded by the health care professional administering them. In clinical circumstances where transcribing occurs it must be underpinned by training, risk

assessment, an audit trail, and have processes in place to limit errors. Organisational safeguards should be in place to ensure that transcribed information is not inadvertently used as a prescription. Transcribing cannot include any changes to the medication, for example, the timing of, or titration of dose, as this becomes prescribing. For further information, please see the guidance on the administration of medicines in health care, available at medicines-management/professional-resources Local policies that support both administrations and transcribing should also be referred to.’ I would suggest you undertake a fact find to understand why the RN did this if she has acted outside her role ie an employed care worker you may need to consider discipline procedures and a safeguarding referral. The NMC may also need to be notified depending on the outcome.

*All information is correct at the time of publishing.

About Sheila

Sheila Scott OBE has now retired and over the years , prior to her retirement she has answered thousands of your social questions. You can still access the many questions below.

For Sheila Scott OBE as the former CEO of National Care Association (NCA), care is Sheila's life. She possesses a strong command of the issues facing the care sector informed by her long career as a nursing professional, the owner and manager of a care business, and as a leader in the care sector.

Please do get in touch with our team of specialists if you can’t see an answer to the question you may have and we will be happy to help.

Here at QCS we have an extensive panel of specialists with a wide range of knowledge and experience so don’t worry if you have a social care question you are struggling to find the answer to, our team are here to help.

    Join over 130,000 users already using the QCS Management System!
    Start Free Trial Buy Now
    Back to Top