To verify whether a specific antibiotic was administered, the CDI professional should review which record?

To verify whether a specific antibiotic was administered, the CDI professional should review which record?

• A. Medication administration records (MARs)
• B. Pharmacy fill log
• C. Electronic health record notes
• D. Nursing progress notes

Answer: (A)

The essential idea here is knowing where to confirm that a specific antibiotic was actually given to a patient. The medication administration record (MAR) is the dedicated, time-stamped log that nurses use to record every dose of medication administered, including the drug name, dose, route, exact time, and who gave it. Because MAR captures each administration event in a standardized, auditable way, it provides the most reliable evidence that the antibiotic was given as prescribed. Other records have roles, but they aren’t as definitive for this purpose. The pharmacy fill log shows when the medication was dispensed by the pharmacy, not whether it was administered to the patient. Electronic health record notes can include orders or narrative entries but may not document every administration event in a consistent, real-time manner. Nursing progress notes contain care observations and progress, but they aren’t the primary source for a complete administration history and can be incomplete or less timely.

The essential idea here is knowing where to confirm that a specific antibiotic was actually given to a patient. The medication administration record (MAR) is the dedicated, time-stamped log that nurses use to record every dose of medication administered, including the drug name, dose, route, exact time, and who gave it. Because MAR captures each administration event in a standardized, auditable way, it provides the most reliable evidence that the antibiotic was given as prescribed.

Other records have roles, but they aren’t as definitive for this purpose. The pharmacy fill log shows when the medication was dispensed by the pharmacy, not whether it was administered to the patient. Electronic health record notes can include orders or narrative entries but may not document every administration event in a consistent, real-time manner. Nursing progress notes contain care observations and progress, but they aren’t the primary source for a complete administration history and can be incomplete or less timely.