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Evidence Guide: CHCCS424B - Administer and monitor medications

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

The important thing to remember when gathering evidence is that the more evidence the better - that is, the more evidence you gather to demonstrate your skills, the more confident an assessor can be that you have learned the skills not just at one point in time, but are continuing to apply and develop those skills (as opposed to just learning for the test!). Furthermore, one piece of evidence that you collect will not usualy demonstrate all the required criteria for a unit of competency, whereas multiple overlapping pieces of evidence will usually do the trick!

From the Wiki University

 

CHCCS424B - Administer and monitor medications

What evidence can you provide to prove your understanding of each of the following citeria?

Identify situations that pose a potential risk to the safe administration of medications

  1. Based on care plan and/or delegation, access information to enable identification of substance incompatibilities
  2. Identify environmental and/or practice issues that may impact on or contraindicate administration of medication in specific situations
  3. Report potential risks related to medication administration to supervisor or health professional
  4. Confirm client identity and if any allergies exist
  5. Identify drugs and poisons schedules and classifications as determined by law
  6. Identify any limitations on own capability in relation to undertaking delegated medication administration function and report to delegating health professional
Based on care plan and/or delegation, access information to enable identification of substance incompatibilities

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify environmental and/or practice issues that may impact on or contraindicate administration of medication in specific situations

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Report potential risks related to medication administration to supervisor or health professional

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Confirm client identity and if any allergies exist

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify drugs and poisons schedules and classifications as determined by law

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify any limitations on own capability in relation to undertaking delegated medication administration function and report to delegating health professional

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Prepare for medication administration within a variety of settings

  1. Establish authority to assist with medication administration in line with organisation policies, guidelines and protocols and jurisdictional legislative and regulatory requirements
  2. Clarify role in providing assistance with medication administration in line with delegation
  3. Confirm that all dose administration aids are complete, ready for use and up to date
  4. Implement personal hygiene procedures according to organisation policy and procedure to ensure cross infection is minimised
  5. Ensure practice is at all times consistent with policies, procedures and delegations in order to fulfil duty of care requirements
  6. Gather equipment required for medication administration
  7. Confirm medication administration route and associated terminology and procedures for medication administration
  8. Identify from the care plan the purpose and function of prescribed medications for administration
  9. Report environmental and/or practice issues that may impact on or contraindicate administration of medication in specific situations and seek direction from supervisor or health professional
  10. Accurately measure and/or calculate dosages for administration of medication
  11. Prepare medications according to delegated role and in line with legal and environmental guidelines
  12. Demonstrate medication administration techniques and precautions specific to each client as per delegation
Establish authority to assist with medication administration in line with organisation policies, guidelines and protocols and jurisdictional legislative and regulatory requirements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Clarify role in providing assistance with medication administration in line with delegation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Confirm that all dose administration aids are complete, ready for use and up to date

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement personal hygiene procedures according to organisation policy and procedure to ensure cross infection is minimised

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Ensure practice is at all times consistent with policies, procedures and delegations in order to fulfil duty of care requirements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Gather equipment required for medication administration

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Confirm medication administration route and associated terminology and procedures for medication administration

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify from the care plan the purpose and function of prescribed medications for administration

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Report environmental and/or practice issues that may impact on or contraindicate administration of medication in specific situations and seek direction from supervisor or health professional

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Accurately measure and/or calculate dosages for administration of medication

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Prepare medications according to delegated role and in line with legal and environmental guidelines

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Demonstrate medication administration techniques and precautions specific to each client as per delegation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify and prepare the client for administration of medication

  1. Identify the client, including clients who self administer, according to organisation procedures and delegation
  2. Greet correctly identified client and prepare for medication administration
  3. Check client medication according to organisation guidelines and delegation
  4. Inform the client of the administration procedure
  5. Prior to administration, check the client for any physical or behavioural changes that may indicate the need to report to delegating health professional, according to organisation policies and procedures
Identify the client, including clients who self administer, according to organisation procedures and delegation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Greet correctly identified client and prepare for medication administration

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Check client medication according to organisation guidelines and delegation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Inform the client of the administration procedure

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Prior to administration, check the client for any physical or behavioural changes that may indicate the need to report to delegating health professional, according to organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Administer required medications within legal parameters

  1. Administer medications as delegated within role responsibility according to the law and environment policy
  2. Prepare and administer medications according to specific requirements of the form of medication, in strict accordance with defined legislation and organisation procedures, according to delegation and in line with prescriber's written instructions where available
  3. Implement all checks to ensure the right medication is given at the right time, to the right person, in the right amount, via the right route, in the right form
  4. Assist the client taking the medication as required and according to documented procedures
  5. Supervise and observe the client when taking medication and confirm ingestion or completion
  6. Dispose of all used and unused medication, containers, needles and syringes in line with organisation procedures
  7. Identify signs that PRN medications may be required, review care plan and written instructions and act in accordance with organisation's policies, procedures and role responsibility, in line with delegation
Administer medications as delegated within role responsibility according to the law and environment policy

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Prepare and administer medications according to specific requirements of the form of medication, in strict accordance with defined legislation and organisation procedures, according to delegation and in line with prescriber's written instructions where available

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement all checks to ensure the right medication is given at the right time, to the right person, in the right amount, via the right route, in the right form

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assist the client taking the medication as required and according to documented procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Supervise and observe the client when taking medication and confirm ingestion or completion

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Dispose of all used and unused medication, containers, needles and syringes in line with organisation procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify signs that PRN medications may be required, review care plan and written instructions and act in accordance with organisation's policies, procedures and role responsibility, in line with delegation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Monitor client response to administered medication

  1. Record administration of medications according to organisation policy
  2. Contribute to information provided to clients and carers on medication administration, including possible side effects
  3. Identify apparent acute and delayed adverse reactions to medications, respond within role responsibility and report to supervisor or health professional
  4. Implement emergency response for identified acute and delayed adverse reactions within role responsibility
  5. Record and report response to emergency strategies
  6. Identify signs of a client experiencing pain and report to supervisor or health professional
  7. Observe and record client response to pain relieving medication and report to supervisor or health professional
Record administration of medications according to organisation policy

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Contribute to information provided to clients and carers on medication administration, including possible side effects

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify apparent acute and delayed adverse reactions to medications, respond within role responsibility and report to supervisor or health professional

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement emergency response for identified acute and delayed adverse reactions within role responsibility

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Record and report response to emergency strategies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify signs of a client experiencing pain and report to supervisor or health professional

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Observe and record client response to pain relieving medication and report to supervisor or health professional

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Comply with the organisation's procedures for handling the range of issues/contingencies which may arise

  1. Report to supervisor and health professional client refusal to take medication or incomplete ingestion according to organisation's procedures and protocols
  2. Identify contaminated or out of date medication
  3. Implement organisation procedures for disposal of contaminated or out of date medication
  4. Observe and record changes in the client's condition according to the organisation's guidelines and report to supervisor and health professional
  5. Record and report any inconsistency (e.g. with the medication, the time or the client) according to the delegation
  6. Document inconsistencies and address according to the organisation's guidelines and procedures
Report to supervisor and health professional client refusal to take medication or incomplete ingestion according to organisation's procedures and protocols

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify contaminated or out of date medication

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement organisation procedures for disposal of contaminated or out of date medication

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Observe and record changes in the client's condition according to the organisation's guidelines and report to supervisor and health professional

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Record and report any inconsistency (e.g. with the medication, the time or the client) according to the delegation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Document inconsistencies and address according to the organisation's guidelines and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Complete medication distribution and administration

  1. Manage the trolley, or other medication container and used medication containers according to industry and the organisation's infection control guidelines
  2. Complete arrangements and procedures to replenish dose administration aids and supplies
  3. Store medication charts according to the organisation's procedures to ensure safety, security and confidentiality
  4. Complete medication storage procedures to maximise security, prevent medication deterioration and in compliance with legislation
Manage the trolley, or other medication container and used medication containers according to industry and the organisation's infection control guidelines

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Complete arrangements and procedures to replenish dose administration aids and supplies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Store medication charts according to the organisation's procedures to ensure safety, security and confidentiality

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Complete medication storage procedures to maximise security, prevent medication deterioration and in compliance with legislation

Completed
Date:

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Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.

Critical aspects for assessment and evidence required to demonstrate this unit of competency:

The individual being assessed must provide evidence of specified essential knowledge as well as skills

This unit must be assessed in the workplace under the normal range of work conditions

Assessment must be conducted on more than one occasion to cover a variety of circumstances

Assessment must reflect actual delegation from a health professional

Development of assessment tools and methods may include the input of a health professional

Access and equity considerations:

All workers in community services should be aware of access, equity and human rights issues in relation to their own area of work

All workers should develop their ability to work in a culturally diverse environment

In recognition of particular issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on Aboriginal and Torres Strait Islander people

Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on Aboriginal and/or Torres Strait Islander clients and communities

Context of and specific resources for assessment:

This unit can be assessed independently, however holistic assessment practice with other community services units of competency is encouraged

Competency in this unit should be assessed using all the relevant resources commonly provided in the residential care service setting

Specific tools may include:

medication charts and documentation

medications and equipment

relevant policies and procedures manuals

other documentation relevant to the work context such as:
. organisation charts
. floor plans
. instructions for the use of equipment
. specific medication administration instructions
. client care plan
. relevant guidelines and legislation

relevant equipment and cleaning agents currently used in the workplace

Method of assessment:

Assessment will include:

Observation of work performance

Supporting statement of supervisor or health professional

Authenticated evidence of relevant work experience and/or formal/informal learning

Case studies and scenarios as a basis for discussion of issues and strategies to achieve required infection control outcomes in specific work environments and communities

Written assessment of functional English language, literacy and numeracy skills appropriate to the level of responsibility of the care worker

Annual reconfirmation of the essential knowledge and competency by the employer within a performance management framework is mandatory

Required Skills and Knowledge

This describes the essential skills and knowledge and their level required for this unit.

Essential knowledge:

The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

These include:

Clear understanding of principles, practices and regulatory framework underpinning delegation and supervision, accountability and responsibility

Basic understanding of medication groups and categories and their effect on body systems and major disorders, including:

central nervous system

musculo-skeletal system

peripheral nervous system

endocrine system

cardiovascular system

respiratory system

gastrointestinal system

urinary system

reproductive systems

immune system

integumentary system

eye, ear and special senses

micro-organisms

neoplastic disease

Principles of safe medication administration and consequences of incorrect use of medication, main reasons for errors in medication administration

Cross infection and prevention strategies including correct hand washing techniques, glove usage and awareness of how infection is spread

Basic understanding of major factors that affect the action of drugs, including age, disease processes, nutrition, and hydration

Measurement and calculation requirements for medication administration

Relevant medical/medication terminology

Commonly accepted medication abbreviations

Basic knowledge of commonly used medications

Basic pharmacology of medications, including:

pharmacodynamics

pharmacokinetics

pharmacotherapeutics

toxicology

Forms of medication, modes and routes for medication delivery

Legal requirements of each route of administration

Procedures for medication administration routes listed in the Range Statement

How and when to use the equipment listed in the Range Statement

Roles within the health care team in the administration of medications

Role in medical emergency

Basic understanding and knowledge of substance incompatibilities and contra-indications, such as:

warfarin and aspirin

medication and diet

medication and sunlight

Basic understanding of:

anaphylactic reactions

side effects

precautions

Basic understanding of complementary therapies

Legal requirements for practice parameters including Poisons Act, Poison Schedules S4Ds and S8s

Relevant workplace health and safety policies to ensure safe practice, including:

management of sharps

potential hazards in a health environment

chemical use in cleaning and sanitising in relation to medication residue in containers

Appropriate storage of medications

Methods of storage, handling and usage of medications

Organisation procedures for the documentation of medication and the use of medication charts

Essential skills:

It is critical that the candidate demonstrate the ability to:

Read and accurately interpret delegated medication responsibilities from the care plan or other written instructions

Ensure all work is in accordance with supervisor and health professional's instructions

Accurately observe, report and record discrepancies in medications, instructions and/or client

Observe and record changes in the client's condition as listed in the Range Statement, during and after medication administration and report to supervisor and health professional

Provide administration of medications according to the specific delegation and in compliance with legal and organisation policies and procedures, including principles of best practice relating to:

following medication label and/or instructions

work health and safety (WHS)

infection control including correct hand washing

managing and reporting contingencies as they arise

applying standard and additional precautions in infection control

correct documentation of medication administered

Demonstrate the following skills correctly, including specific levels of literacy and numeracy and physical capabilities required:

read and correctly interpret care plan or other written instruction from supervisor or health professional for administration requirements for medications

use dose administration aids

observe, report and record discrepancies in medications, instructions and/or client

report any obvious changes in client's condition as listed in the Range Statement before, during and after self-medication to a supervisor and / or health professional so remedial action can be taken

Negotiate the physical assistance that can be provided

Use equipment listed in the Range Statement effectively and appropriately

Distribute medications in a timely, appropriate and effective way to clients with differing needs and according to form of medication

Apply language, literacy and numeracy required for drug calculation, administration and documentation of medications

Demonstrate correct preparation, administration and recording of medications via delegated routes within the range identified in the Range Statement

Correctly administer and support self-administration of insulin by sub-cutaneous injection using pre-loaded syringes or pens

Skills and knowledge to conduct BSL monitoring including knowledge of the acceptable and safe range of results for an individual client and operating in accordance with organisation's policy and practice and seeking advice and assessment of the health professional when results are outside the acceptable and safe range before administering insulin by sub-cutaneous injection

It is critical that the candidate demonstrate the ability to:

Undertake basic calculations for oral administration of tablets

Safely measure liquids according to directions

In addition, the candidate must be able to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

These include the ability to:

Respond within job role in an emergency situation where a client is experiencing an adverse medication reaction

Oral communication skills required to fulfill job role, including:

interviewing skills

questioning

active listening

seeking clarification

Range Statement

The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.

Potential risk may include but is not limited to:

Client identification

Allergic reactions

Immunisation status

Medication incompatibilities

Delegation refers to:

Conferring of authority to perform specific medication administration activities to a worker not usually authorised but who has been determined as appropriate for the task by the delegating health professional

Delegation is within the context of a care plan or other written instruction

Where delegation is provided verbally it must be confirmed as soon as practicable according to organisation procedures in writing and incorporated in the care plan

The authority is specific to an individual client within a specific care context and is not transferable

Delegation instructions must include:

medication and its purpose

medication form and instructions e.g. enteric coated - do not crush

dosage and related instructions

route

contra-indications

any other relevant instructions or information, especially information specific to the client

Supervision refers to:

Instructing, advising, and monitoring another person in order to ensure safe and effective performance in carrying out the duties of their position

Supervision may be conducted by various means including:

in person

through use of electronic communications media such as telephone or video conferencing, where necessary

Supervision level, form and frequency must be established by the delegating health professional for all work delegated to another worker

Frequency and form of supervision will be determined by factors such as:

the task maturity of the person being supervised

the need to review and assess client conditions and progress in order to establish or alter treatment plans

The need to correct and develop non-clinical aspects such as time management, organisation requirements, communication skills, and other factors supporting the provision of clinical care and working within a team

Health professional includes:

Registered nurses

Medical practitioners

Pharmacist

Complementary medicine therapist (for delegation within legislative requirements, specific to their area of expertise where included in the care plan)

Dentist

Settings may include:

Aged care residential

Client's home

Group home

Respite service

Dose administration aids may include:

Blister packs - single dose packs and multi-dose packs

Equipment required may include:

Aprons

Container for dirty spoons/dishes

Medication charts/sheets

Gloves

Key to medication trolley/medication cupboard

Lubricant

Measuring cups

Measuring spoon

Mortar and pestle

Nebuliser/spacer

Oxygen cylinder

Oxygen mask/nasal prongs

Pre-loaded dose administration aids for insulin

Paper towels/tissues

Tablet divider

Tea towel

Tumblers

Water pitcher

Medication administration routes include:

Aural

Insulin by sub-cutaneous injection using pre-loaded syringes or pens

Intranasal

Ocular

Oral

Rectal

Topical (including transdermal)

Vaginal administration

Measure and/or calculate dosages includes:

100% accurate measurement and/or calculation of medication required as per written delegation and/or prescription, including:

measurement of liquid medications into measuring cup or spoon

calculation of medication mixtures and solutions

use of standard formulae to calculate the number or fraction of tablets to be administered to equate to required dose

calculation of the number or fraction of tablets to equate to identified weight

Prepare medications may include:

Dispensing tablets from dose administration aids into medicine cup

Measuring liquid medications into measuring cup/spoon

Dissolving powder in water

Placing medication in nebuliser/spacer

Use of lubricant

Medication administration techniques may include, for example:

Techniques to assist clients with difficulties swallowing

Techniques to assist clients with specific disabilities

Techniques for managing behaviours of concern

Prepare for medication administration may include:

Discussing procedures with client

Encouraging client participation

Adjusting posture and positioning client

Seeking assistance from other staff

Providing privacy

Exposure to treatment area

Check client medication may include:

Checking medication is free from contamination

Checking that medication, time and resident/client correlate with documentation

Checking dose administration aids for evidence of tampering

Physical or behavioural changes observed in condition of the client that must be immediately reported to a supervisor or health professional may include, but are not limited to:

Changes to airway (e.g. choking), breathing (including slowed, fast or absent breathing, colour changes) or circulation (including unexpected drowsiness, colour change and absence of pulse)

Rash

Inflammation or redness

Swelling

Headache

Skin tone

Feelings of dizziness

Slurring of speech

Nausea and vomiting

Blurred vision

Confusion

Changes in behaviour

Anything that appears abnormal about the resident/client

Others as advised by a doctor or health professional

The form of medication may include:

Capsules

Ear drops

Eye drops

Inhalants

Liquid

Lotion and cream

Nose drops

Patches

Pessaries

Powder

Pre-loaded syringes or pens

Suppositories

Tablets

Wafers

All checks include:

Checking medication against the requirements

Checking client details

Checking the chart

Checking for authorisation

Checking specific delegation

Incomplete ingestion includes:

Inability or difficulties in swallowing whole or divided tablets

Ejection of medication

Vomiting

Refusal to take medications

Document inconsistencies may include:

Incident reports

Medical charts

Progress notes

Drug storage procedures include:

Acting in accordance with defined job role

Locking and storing medications according to organisation policy and procedure

Required medications may include:

Medications prescribed for client by doctor or health professional and dispensed by pharmacist in dose administration aids

PRN medications as prescribed (and identified in medication chart/sheet and/or care plan) according to relevant legislation, organisation guidelines and delegations

Client identification may include:

Referral to forms of identification such as photographs, wristbands

Recognition by response

Confirmation from nursing/care staff

References may include:

MIMS annual or drug reference guide

Drugs hotline/drug information line

Industry guidelines may include:

Australian Pharmaceutical Advisory Council Integrated best practice model for medication management in residential aged care facilities

State and territory health department legislation, policies and guidelines

Organisation policies and procedures

Internal facility medication audits