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MEDICATION ADMINISTRATION RECORD

Consumer Nam e:

MEDICATION

HOUR

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Attending Physician:

 

 

 

 

 

 

 

 

Month:

 

 

 

 

 

 

 

Year:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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R = R E F U S E D

D = D I S C O N T I N U E D H = HO M E

D = D A Y P R O G R A M C = C H A N G E D

R E M E M B E R T O R E C O RD A T T IM E O F A D M I N IS T R AT I ON

Document Information

Fact Name Description
Purpose The Medication Administration Record (MAR) sheet is used to document the administration of medications to consumers in a healthcare setting.
Consumer Information Each MAR sheet includes essential consumer details, such as their name and the attending physician's name, ensuring accurate record-keeping.
Medication Hours The form provides designated columns for each hour of the day, allowing healthcare providers to track when medications are administered.
Month and Year MAR sheets include fields for the month and year, which help in organizing records chronologically for easy reference.
Refusal and Discontinuation Codes Specific codes, such as R for Refused and D for Discontinued, are included to indicate any changes in medication administration status.
Home and Day Program Indicators The sheet contains indicators for Home (H) and Day Program (D) to clarify the setting in which the medication was administered.
Record Keeping Reminder A reminder is included on the form to record the time of administration, emphasizing the importance of accurate documentation.
State Regulations In many states, the use of MAR sheets is governed by healthcare regulations that mandate proper documentation for patient safety and legal compliance.

Medication Administration Record Sheet - Usage Guidelines

Completing the Medication Administration Record Sheet is essential for ensuring that medications are administered accurately and tracked effectively. Follow these steps carefully to fill out the form correctly.

  1. Start by entering the Consumer Name at the top of the form. Make sure to spell it correctly.
  2. Next, write the Attending Physician's Name in the designated space.
  3. Indicate the Month and Year for which you are recording the medication administration.
  4. In the section labeled MEDICATION HOUR, list the hours during which medications are to be administered. This typically ranges from 1 to 24, depending on the schedule.
  5. For each day of the month, mark the appropriate box for each medication administration. Use the following codes:
    • R = Refused
    • D = Discontinued
    • H = Home
    • D = Day Program
    • C = Changed
  6. Be sure to record at the time of administration to maintain accurate records.

After completing the form, review it for any errors or omissions. This ensures that the information is accurate and up-to-date, contributing to the safe administration of medications.

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Dos and Don'ts

When filling out the Medication Administration Record Sheet, consider the following guidelines:

  • Do write clearly and legibly to ensure all information is readable.
  • Do use the correct medication names and dosages as prescribed.
  • Do record the date and time of each medication administration accurately.
  • Do indicate any refusals or changes in medication status promptly.
  • Don't leave any blank spaces; fill in all required fields completely.
  • Don't use abbreviations that may cause confusion.
  • Don't alter any entries after they have been recorded without proper documentation.
  • Don't forget to sign or initial the record after each administration.

Common mistakes

  1. Incomplete Consumer Information: Failing to fill out the consumer's name or other essential details can lead to confusion. Always ensure that the consumer's name is clearly written at the top of the form.

  2. Incorrect Medication Hour Entries: Mistakes often occur when entering the time medications are administered. Double-check that the correct hour is marked for each medication to avoid any potential overdoses or missed doses.

  3. Omitting Attending Physician's Name: Leaving the attending physician's name blank can create issues with accountability. Always include this information to ensure proper communication and oversight.

  4. Neglecting to Use the Correct Abbreviations: Using incorrect abbreviations for medication status can lead to misunderstandings. Familiarize yourself with the key abbreviations such as R for Refused and D for Discontinued.

  5. Failing to Record Administration Times: It is crucial to document the exact time medications are given. Not recording this information can hinder proper tracking of medication schedules.

  6. Inconsistent Record Keeping: Inconsistencies in how records are kept can lead to significant errors. Ensure that all entries are made in a uniform manner to maintain clarity and reliability.

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