Medication Self Administration

If you are ever unsure about any aspect of assisting a person to take his/her medication(s), stop, contact your supervisor or other person designated by your agency, and get clarification before you continue.

1. Definitions
Assistance means the help or aid necessary to complete a function or a task.

The Direct Support Professional may provide the assistance necessary for a person to take his/her medication.

Direct self-care means a person is able to recognize danger, summon assistance, express need, and make basic care decisions.

A person who is able to “direct self-care” can instruct the Direct Support Professional to assist by opening the medication bottle; placing the medication in his/her mouth and providing a drink of water.

Directed care services means programs and services, including personal care services, provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions.

When providing “directed care services,” the Direct Support Professional may provide assistance by taking direction from the responsible person, including providing the help necessary for the person to take his/her medication.

Documentation means written supportive information.
The Direct Support Professional must keep documentation by recording the date and time of day when assistance with medication self- administration was provided.

Where to find information about providing assistance with medication self-administration

The person’s Individual Support Plan (ISP) provides support information about medication(s) taken and the amount of assistance needed for medication self- administration. The ISP states whether the consumer needs assistance in the self- administration of medication and any special instructions about the type of assistance:

1. Requires no assistance in the self-administration of medication or medication administration;

2.  Needs assistance in the self-administration of medication, which can include:

•   Reminding a consumer that it is time to take a medication;
•   Opening a medication container for a resident;
•   Pouring or placing a specified dosage as instructed by the consumer into the consumer’s hand;
•   Observing the consumer while the medication is taken; or
•   Assisting the consumer to take the medications that have been prepared in advance in a medication organizer by the responsible person.

3.  Needs total assistance, which includes use of medication organizers.

 Medication organizers may be prepared in advance by the responsible person. There need to be clear, simple instructions from the responsible person. Example: The medication needs to be in a container that is clearly marked, “Please give to my mother at 10 am with a glass of water.” (Only the exact dose is in the container so that the DCW does not have to decide how many pills to use.)

 What to document

Document that medications were administered according to the consumer’s instructions or according to medication organizer date and time, as directed by the responsible person.

What you can not do

•   A DCW cannot use professional judgment and cannot make decisions about medications.
•   If the consumer does not know which medication is which, the DCW cannot help figure this out.
•   If the consumer is confused about dosage/time etc., the DCW cannot help sort it out.