What should be included in all records along with the entry?

Including both the date and time in all records is essential for maintaining accurate and reliable documentation in medication administration. This practice ensures clarity regarding when a specific medication was administered or a particular action was taken.

The inclusion of the date helps establish a timeline for the patient’s care and treatments, while the time of administration provides precision that can be critical for medication dosing schedules, especially in cases where timing is crucial for effectiveness and safety.

Accurate documentation can also assist healthcare professionals in tracking the effects of medications, ensuring compliance with prescribed regimens, and facilitating communication among team members involved in the patient's care. Clear and detailed record-keeping supports continuity of care and safeguards against medication errors or miscommunication.