One of the biggest challenges care organisations have is in ensuring that they have good Medication Administration Records and that their nurses and care staff actually complete them correctly. I recently had the pleasure of the company of a gentleman from the Care Quality Commission who told me that medication issues are still the greatest area of concern during inspection visits and particularly record keeping. So what are the issues and how can we get it right?
What information should be on a MAR?
The guidance states that a MAR should contain the name and address of the service user, a start date so that I know which record is current or for reference should I need to go an look back at a certain date, the medication details i.e. the name, strength, form, clear dosage instructions and times of day, to state "contents of box" or nomad or dossette etc.is not acceptable, if you have codes for administration then the key for those codes needs to be clearly stated on the MAR, some where for the nurse or carer to either sign or initial, if initials are used there needs to be a master record kept in the office of whose initials tally with which carer or nurse.Any other information on the MAR is not necessary but may make the MAR more robust when in use and so may have quantities received and returned for example, or GP details etc.
Who is responsible for providing the MAR and entering the information?
Legally it is the responsibility of the care organisation to provide the MAR and to put the information on it. Many care homes will have their MAR's provided by their pharmacy but it actually is a complimentary service to them, pharmacy have no legal or contractual obligation to provide MAR's at all. There is no official template or recommended format for a MAR and so there are many different types and as long as they meet the requirements above and are filled in correctly it's what works best for your organisation. The medication information for each client should be entered by the company and any changes to medication should also be made by the care company, written in legibly in ink, if the medication has changed, put a line through the old medication and re-write the new on a new line of the MAR, preferably checked by another person, signed, dated and a note to say on who's authority was the change made.
Codes for Administration
There are no official codes for administration or guidance given as to what they should be so it is up to the care organisation to decide what information it requires the nurse or carer to record. Good practice would be to have codes for administered, reminded, observed, not taken, refused, dose measured, on leave, in hospital,etc.
Record keeping at the time of administration
Training in how to complete MAR's is essential if you are to ensure that your teams do it correctly at all times. You should have in place a system to identify where mistakes are being made or records are not being completed properly so that that carer or nurse can be spoken to, given additional guidance and training and standards enforced.
At the time of administration team members must sign or initial the MAR in the appropriate space and an indication of how they supported, this may be by using a code as discussed above. If the person did not require medication the carer or nurse should still sign and add a code to explain that the client didn't require it. Please do not leave records blank as gaps create questions and uncertainty about what happened at that time. If it was a controlled drug administered by two people both should sign. If it was a variable dose for example "give 10ml or 20ml", exactly what dose was given should be recorded. If a dose is refused by the service user record that it was refused and why. Any over the counter remedies or homely remedies that you administer should also be detailed on the MAR.
For further information, training on record keeping or examples of good MAR's you might model contact firstname.lastname@example.org or call 01793 700929