What must medication documentation always include?

The inclusion of the date and time of administration in medication documentation is crucial for several reasons. Firstly, it provides a clear timeline of when the medication was administered, which is vital for monitoring the patient's response to treatment and ensuring that medication is taken at the correct intervals. This information helps healthcare providers assess whether the medication is effective and whether any further doses are needed.

Additionally, accurate documentation of the date and time aids in avoiding potential errors such as doubling doses or neglecting to administer scheduled medications. This practice ensures patient safety and enhances the continuity of care, allowing other healthcare providers to easily understand the patient’s medication regimen and adherence.

While other aspects of documentation, such as a healthcare provider's signature or pharmacy details, are important in the context of overall medication management and accountability, they do not directly impact the immediate administration and monitoring of medication at the patient level as much as the date and time do.