Where should all medications, dosages, and frequency of dosage be documented?

Documentation of all medications, dosages, and frequency of dosage should be recorded in the inmate's medical file. This is essential as the medical file serves as a comprehensive record of an inmate's health history and treatment plan. It ensures that all healthcare providers accessing the file can easily review the medication history, verify prescribed treatments, and make informed decisions regarding future care.

By maintaining accurate records in the medical file, it also supports continuity of care and may be necessary to comply with legal and regulatory standards governing healthcare in correctional facilities. Proper documentation in the medical file is crucial for protecting the rights of inmates and ensuring that they receive appropriate medical attention.