Importance of Medication Record Keeping

1. Understanding Medication Administration Records (MAR)

Correct recording of information is vital in medication management within Health and Social Care organisations. This involves maintaining a comprehensive paper trail from prescription to administration and disposal.

a. Medication Administration Record (MAR) Chart

MAR chart stands for Medication Administration Record chart, which contains essential details about the medication and its administration.

• Information Included:
• Name and date of birth of the service user
• Name of the medication
• Route of administration
• Frequency of administration
• Code to explain reasons for omission of a prescribed dose (e.g., N for Nausea or Vomiting, R for refusal)
• Date of prescribing and any known allergies (recorded in red)
• Special instructions or requirements

b. Recording Errors and Special Instructions

Any errors must be crossed through, and all records must be made in black ink. Special instructions or requirements, such as taking medication with or after food, must be noted.

2. Importance of Keeping Records

At every stage of medication administration, meticulous records must be maintained, including receiving, administering, disposing of, and returning medicines to the pharmacy.

a. Administering Medication

When signing the MAR chart to confirm medication administration:

• Check each medication in the blister pack against the medicine pot.
• Place a dot in the corresponding box on the MAR chart once the service user has taken the medication.
• Initial the corresponding box for each medicine taken.

b. Signature Record

Ensure a copy of your signature is recorded within the care home for identification purposes.

3. Conclusion

Record keeping is a shared responsibility among all staff in the care home. Accurate and comprehensive records are crucial for accountability and continuity of care.