Question

Documentation Exercise Scenario: Question 54 refers to this scenario. You are caring for Dean Odell, a 58-year-old male patient who was admitted on August 11, 2022. His date of birth is 06/06/64. His hospital ID number is 9607890. Mr. Odell has an order for digoxin 0.25 mg to be given at 9:00 a.m. daily. Today is August 12, 2022. You check his digoxin level and find that it is 2.0 ng/mL. When you check his pulse, you count it at 56 beats per minute. You hold the medication and notify the health-care provider. At 9:25 a.m. you speak with Dr. Marvel by telephone. He gives orders to stop the digoxin 0.25 mg, to give no digoxin for 2 days, and then restart it at 0.125 mg daily. 54. Document your actions on the MAR (Fig. 36.1), the nurse's note form (Fig. 36.2), and the health-care provider's order form (Fig. 36.3).

Answer 1

MAR FORM

Date ordered	Date record	Drug-Dose_Route-Frequency	Admin time	Date	Date	Date
August 11 2022	August 11	Digoxin-2.0ng/ml-PO-	9.00am	11/08/2022
	12/08/2022	Digoxin 0.25mg	9.00am	DISCONTIUED FOR NET TWO DAYS (TILL14/08/2022)

15/08/2022

Digoxin 0.125mg daily

9.00am

Signature

Nurse administering the medications

2.In the nurses note form;

DATE;12/08/2022

9;00 am - Patient Mr..Dean Odell was assessed before the digoxin administration. His digoxin level is 2.0ng/ml and pulse rate 56 beats. Witheld the medication and informed health care provider.

9.25am - Telephonic conversation with Dr. Marvel. Advissed to stop dioxin 0.25 mg for the next two days (till14/08/2022) and restart it with0.125 mg daily.

3. Health careprovider form;

Date;12/08/2022

09;25am ; Telephonic order from Dr. Marshell. Withold Digoxin 0.25mg till 14/08/2022 and restart on 15/08/2022 wth 0.125mg dose daily.