What is a MAR chart?
A MAR chart stands for a Medication Administration Record and is a working document used to record administration of medicines. All medicines for a customer should be listed on an individual MAR chart, whether they are prescribed by a GP or if they are bought over the counter, and it is extremely important that all information is recorded clearly, accurately and is kept up to date.
If an individual requires medication, there must be a MAR chart that details:
- Which medicines are prescribed for the individual
- When they must be given
- What the dose is
- Any special information, such as giving the medicines with food, or time-specific medications
MAR charts can also be used to check and sign medication into the home, carry forward medication from the previous month and to record any circumstances under which medication has not been administered using the key provided on the MAR chart e.g. refused, nausea/vomiting. MAR charts last for one month and are then replaced by a new sheet.
When regular medication changes or is added to a customer’s medication profile, carers may make amendments to the existing MAR chart.
If there are any ever discrepancies between the MAR chart and any other directive e.g. medicine labels or prescriptions, the pharmacy or prescriber must be contacted by the carer before administration to confirm the correct instructions; the MAR chart must then be amended as necessary.
Care Quality Commission (CQC) requirements state that MAR charts must be filled out immediately after administration by the person who gave the medication. This ensures that all correct persons are accountable and that there are no omissions on the MAR chart.
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Can a live-in carer administer medication?
For customers receiving live-in care, carers are able to administer medication, but only if the support plan states that the customer requires this AND if the carer has received the correct training.
Carers must always comply with the support plan and the instructions provided – in some cases, customers may be able to administer some of their medications independently or with gentle prompting, but not others. For example, a customer may not need support to take tablets orally but may be unable to apply creams themselves and require their carer to do this for them.
What type of medication can a live-in carer administer?
Our award-winning training covers all aspects of general medication, including how to administer medication, how to record and use the MAR chart correctly, assisting with the opening of blister packs and using dosette boxes. All of our live-in carers are able to administer non-complex medication, such as:
- Tablets and liquids (orally)
- Ear or eye drops
- Creams
- Inhalers
Specialist clinical training is required for the following:
- Continence care – including stomas and catheters
- PEG feeding
- Tracheostomy care
- Ventilated care
Our experienced team of clinical nurses deliver complex medical care training to our carers and oversee the care for customers who have complex conditions. They ensure that carers are fully equipped to support customers with a range of different conditions that require specialist medical care – from stroke aftercare to rehabilitation after an acquired brain injury.
For more information on our 24-hour care services, please click here.
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Documenting Medication Administration
Covered in this topic:
Documenting Administration
Scheduled Medication Example
Incomplete Status Medication Example
PRN Medication Example
Documenting Administration
The electronic Medication Administration Record (MAR or eMAR) is used to electronically track and record administration of most medications at UHN. The MAR serves as a legal document for UHN’s drug administration, with the exception of out-of-scope drugs that are currently still being documented on paper. See topic Preparing Medications for details on administration.
Regardless of the type of medication, you can follow these common steps to document administration:
1. Select the relevant dose/medication; click OK.
2. Enter the date/time the medication was administered; click OK.
Note: Accurate documentation of administration time is integral to ensuring accurate future dosing and records.
3. Carefully review the details of the order, as you will be attaching your electronic signature stating you administered exactly as laid out in the order fields.
4. Check Status column for flag of incomplete fields.
a. If blank, continue to step 4.
Note: Clinicians should always document any information that they deem clinically relevant regardless of what EPR is prompting (ie. an empty Status column will not block you from doing step b).
b. If Incomplete is seen, choose the Continue Editing button, select the medication, and complete the bold/mandatory fields that are empty and whatever other information the clinician deems noteworthy.
5. Choose the Administer All button.
6. Choose the Accept button to save.
7. Double-check the MAR grid to ensure your documentation saved. The date and time will appear in the Last Admin column and the dose symbol will be gone from the grid.
Note: For medications with a one-time dose only, once administration has been documented in EPR it will no longer appear on the MAR.
Scheduled Medication Example
Medications ordered by the Prescriber with a specific dose schedule (i.e. q4hrs or q12hrs) will appear under the Scheduled Orders section of the MAR. A symbol of will represent each dose under each relevant time column.
Doses scheduled out on the MAR must be reconciled with either an administered, cancelled or rescheduled status; they cannot be left on the MAR indefinitely.
For example, if a physician verbally instructs the RN to stop giving a medication, but does not place the EPR Discontinue Order in a timely fashion, doses will continue to be scheduled on the MAR. In this case, the RN must manually cancel the scheduled dosage from the MAR to prevent clinical hazards. For more information, see topics Cancel A Dose and Reschedule A Dose.
1. From the MAR, select the medication by clicking the cell that represents the medication and the respective dosage time, and click OK.
2. Enter date and time the medication was administered and click OK.
3. Carefully review the details of the order.
4. Check Status column for flag of incomplete fields.
5. Choose Administer All.
6. Choose Accept.
7. Double-check the MAR grid.
Incomplete Status Medication Example
Incomplete Status indicates that at least one bold/mandatory field is empty and needs to be completed. This can happen for Scheduled or PRN medications.
1. Select the relevant dose/medication; click OK.
2. Enter the date/time the medication was administered; click OK.
3. Carefully review the details of the order.
4. Check Status column for flag of incomplete fields.
5. Click on Continue Editing.
6. Select the medication for editing and click OK.
7. EPR will always alert you as to what is mandatory to document. Complete the mandatory field(s). For a review of fields, see Order Entry Overview topic.
8. Confirm your information is correct and click OK.
9. The status of incomplete no longer exists. Click OK.
10. Choose the Administer All button.
11. Choose the Accept button to save.
12. Double-check the MAR grid.
PRN Medication Example
Documenting a PRN medication follows the same steps as above with two key notes:
Step 1 you can click anywhere on the row.
Step 3 is especially important because you are only documenting a very specific dose amount as defined by the way the order was placed by the prescriber. You may in fact need to repeat steps 1-7 if you gave a double-dose for example.
1. To select the PRN medication, click anywhere on the medication row. Click OK.
2. Enter the date/time the medication was administered; click OK.
3. Carefully review the details of the order.
4. Check Status column for flag of incomplete fields
a. If blank, continue to step 4.
Note: Clinicians should always document any information that they deem clinically relevant regardless of what EPR is prompting (ie. An empty Status column will not block you from doing step b).
b. If Incomplete is seen, choose button Continue Editing, select the medication, and complete the bold/mandatory fields that are empty and whatever other information the clinician deems noteworthy.
5. Choose the Administer All button.
6. Choose the Accept button to save.
7. Double-check the MAR grid.
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