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Correct recording of information is just as important as the administering of the medication. There always has to be a paper trail, from prescription to administration, then from storage to disposal. Within Health and Social Care organisations, you will have a MAR chart, this is the Medication Administration Record chart. The MAR charts will be dispensed by the pharmacy and given along with the medication. On rare occasions, staff may have to transfer the information from the pharmacist onto the MAR chart, but usually this is given by the pharmacist.

The Medication Administration Record will contain the following information: Name and date of birth of the service user, the name of the medication, the route of the medication, the frequency administration, and a code to explain the reasons for omission of a prescribed dose. There will be a code on the back of the form, it could be; N, for Nausea or Vomiting, R for refusal, or L for client on leave; any failure of medication to be administered must be written on the back of the MAR chart. The date of prescribing and any known allergies must also be recorded in red, along with any special instructions or requirements, for example, is the medication to be taken with food or after food? Any errors must be crossed through and all records must be made in black ink.

At every stage of medication administration, records must be kept. This includes medicines received, medicines administered, medicines disposed of, and medicines returned to the pharmacy. With regards to signing the MAR chart to say that you've administered the medication, always ensure that you check each medication that is in the blister pack is in the medicine pot, and you can place a dot in the corresponding box on the MAR chart, once the service user has been seen to take the medication. Staff can then put their initials in the corresponding box for each medicine taken. Never ask a colleague to give medication for you and sign on your behalf, because you don't actually know that medication has been taken. Also, never leave medication unattended. The service user may say, "Oh, I'll take it later." but this is not acceptable. If you are signing then you must ensure that they have actually taken it and swallowed it. Somebody else may come along and pick up that medication, and you don't know that the service user isn't storing up the medication.

Another thing to ensure is that a copy of your signature is recorded within your care home. There should be a list of your signatures, initials and printed name so that this can be easily identified at a later date. Record keeping is extremely important and is a responsibility of all staff in the care home. These records will be around for a long time and could be looked up in five or ten years time if necessary. You won't have any recollection of what happened that long ago, so there needs to be a constant paper trail.