Adding observations

The medication administration process supports real-time clinical observation recording during medication rounds, ensuring accurate documentation, timely clinical communication, and improved visibility of resident status. Observations can be captured directly at the point of care and reviewed within the resident’s medication chart to support safe and consistent clinical decision-making.

During a medication round, staff can quickly record an observation by selecting Comment within the medication administration screen. This allows immediate documentation of relevant clinical findings at the time of medication administration, supporting accuracy and reducing the risk of missed or delayed recording.

Once the observation has been recorded, the medication can be administered as per the prescribed chart. This ensures that clinical context and medication delivery are documented together, supporting safer and more complete medication records.

To support safe interpretation of icons and system indicators, users can select the blue legend button, which provides a visual guide to medication and observation symbols used within the system.

1. During a medication round record an observation by clicking on Comment
    

   
    

2. Record the observation and administer the medication. 
   
   
    

3. To view the legend, click on the blue button.
    

   
    

   To add or review observations outside the administration screen, users can do this from the resident’s medication chart.

4. In the resident's medication chart, click on More.
   
   
    
5. Click on the relevant observation that needs to be recorded
   
   
    
6. Enter the result, any comments and click on Save.
   
   
   To support clinical review and early identification of changes in condition, users can view graphical trends of recorded observations.

7. To view the graph, click on View Graph.
   
   
   All observations recorded through either the medication round or the medication chart is securely stored within the resident’s electronic medication record. This ensures a consistent and auditable clinical history that supports accountability, compliance, and continuity of care across all care team members.

   Real-time recording at the point of care enhances clinical safety by ensuring observations are captured alongside medication administration activities, reducing the risk of omission or delayed documentation.