1 | JJustad, MD, DDP September 2019
FILLING OUT MEDICATION ADMINISTRATION RECORDS
The ABC’s of charting include:
A. Accurate
B. Brief
C. Completely objective
A medical or health record is the collection of all pertinent facts concerning a person’s
illnesses, treatment, and past medical history. The medical record is an important tool that
serves as a basis for planning care, communicating between medical providers and other
workers, and providing documentation as to the course of illness, treatment, and response
to treatment.
A medical record:
• is confidential! Never share information or discuss the individual with anyone not
administering care to that individual.
• must have all accounts of the person’s condition and care in writing and signed by
the person giving care.
• should reflect observed facts, not opinions or judgements.
The Medication Administration Record (MAR) is used to document medications taken by
each individual. A MAR includes:
1. A column that lists the names of medications that are prescribed
2. The times and dates the medication is to be taken
3. The initials of the person assisting with the medication
4. A start date should be noted; a stop date is noted when known
5. Identifying information about the individual, including date of birth, allergies,
diagnoses, and names of medical providers.
Taking the information from a medical provider’s order and transferring them to the MAR
is known as “transcribing”. Sometimes the pharmacy provides completed MARs but if a
new medication is started and a pharmacy generated MAR is not available, you will need to
transcribe that order onto the MAR. This ensures that others know that a new medication
has been prescribed. Changes to the MAR should also be made if the dose of a medication
is changed.
2 | JJustad, MD, DDP September 2019
Charting Rules:
Below are the general rules which apply to charting.
1.
The medication column should be completed by an authorized person. Make
sure you are familiar with the medications listed, doses ordered, and any
abbreviations used.
2.
After assisting with someone’s medications, place your initials below the correct
date and opposite the medication that was taken. Do this only after you observe
that the person has swallowed the medication or if the medication was applied or
otherwise given as directed. Do not initial that a medication was given before it is
administered.
3.
Your initials and signature must be in an appropriate space on each MAR. Each MAR
or set of MARs needs to have your signature and the initials you use to chart when
you have given a medication.
4.
Ditto marks are never used.
5.
Never erase or use any kind of liquid eraser. If you make an error in recording,
draw a single line through the error, then initial and date that spot.
6.
Record onto the MAR immediately AFTER you see that the medication was
swallowed (if taking an oral medication) by the individual. This is the only way to
be sure that you are charting the right medication, giving it to the right person, at
the right time, by the right route and that you can be certain that the medication
was taken.
7.
If a medication is not taken as ordered for any reason, put your initials in the
appropriate box, circle the initials, and note the reason on back of the MAR.
Notify the appropriate person regarding your actions.
8.
If the person refuses the medication continue to make attempts to assist the
person with taking the medication. However, if you run out of the window of time for
taking the medication and the person still refuses, place a circle in the box, write
your initials inside this circle, and chart the reason for the refusal in the notes on
the back of the MAR. Notify the appropriate person of this refusal. If the
medication was set up, you cannot return it to the container; you must dispose of it.
3 | JJustad, MD, DDP September 2019
1. FILLING OUT THE MEDICATION ADMINISTRATION RECORD
• Filling out the MAR may appear difficult, but it is actually quite simple.
1. Simply write down the information from the prescription in an organized
fashion so that you do not make mistakes or forget to record anything.
2. Transcription errors are common and can be fatal.
3. Pay close attention to what the prescription states and how you
transcribe it onto the MAR.
4. If you are unsure of the directions or anything else on a prescription, ask
the prescriber or pharmacy to clarify.
• Even if the pharmacy provides a completed MAR, knowing how to fill it out will
ensure that you know how to read and follow it correctly plus you may have to
add a medication or change a dose on a current medication during that month.
You must know how to transcribe an order onto it.
• If you know how to transcribe onto a MAR, you will be better prepared to notice
any errors that may be on the MAR.
• If the MAR comes filled out by the pharmacy, you should check the orders you
have from the prescriber against what is on the MAR. Pharmacies have been
known to make mistakes.
Following are examples of prescriptions and the Medication Administration Record
(MAR) that would be filled out based on that prescription. The MAR forms used have
larger squares for information than most MARs that you will see. This is for ease of
learning. Because of the larger squares, only the first part of a month will be shown.
When you take your certification test, you will be given information
and a prescription similar to the examples shown. You must be able
to read and understand the information on the prescription and be
able to correctly fill out the MAR. You will not be given assistance
with any portion of the test; you must understand this material and
be able to fill out the MAR. You must also be able to find mistakes
on a MAR to complete another section of your test.
4 | JJustad, MD, DDP September 2019
Example # 1
You took Joe Smith to see Dr. Davis because of his runny nose and cough. Dr. Davis
diagnosed him with bronchitis and allergic rhinitis and has prescribed the following
medications. You picked up the prescriptions at 2 pm on January 3
rd
. You first compare the
prescription information from the pharmacy with the copy of the prescription given to you by
the physician. Then you fill out the MAR and give the first dose of medication. You also note
that Joe is allergic to Penicillin.
Davis and Hartman Medical Group, PLLC
1011 Jackson
Helena, MT 59601
406-442-6779
Date: January 3, 2015
Name: Joe Smith
Birthdate: 11/16/58
Rx:
Allegra 60 mg
Sig: one tablet po BID
Disp: 60
Refill x 1 year
Zithromax 250 mg
Sig: two tabs po today, then one tablet po qd until gone
Disp: 6
Signed: Ron Davis, MD
Ron Davis, MD
5 | JJustad, MD, DDP September 2019
2. THE PRESCRIPTION
Before transcribing onto the MAR, first look at the prescription. Above is an example
of the way that prescriptions may look if hand written. You may encounter electronic
prescriptions, but they will contain the same information in a slightly different format. All
prescriptions should contain:
1.
The date the prescription was written
2.
The name of the person
3.
The birthdate of the person
4.
The medication(s) prescribed
a.
Name of medication
b.
Dose of medication
c.
Instructions for taking the medication. Some prescriptions will not signify
“po” as the route for taking the medication. Unless some other route is
given, assume that the medication is taken by mouth and write that on
the MAR.
d.
The number of pills or amount of medication prescribed or the number of days
that the medication is to be taken.
e.
Refills (if applicable)
5.
The signature and name of the physician
You are expected to know the basic abbreviations used on prescriptions and be able
to translate and transcribe those to the MAR. The MAR should not have abbreviations
on it except for such things as milligrams (mg), grams (g), or micrograms (mcg).
3. THE TIMES OF DAY
You must understand when in the day a medication is supposed to be taken according
to how it is written on the prescription:
• BID, TID, or QID means that a medication is given twice, three times, or four
times a day during the awake hours rather than at exact intervals over 24 hours.
o BID does not mean 12 hours apart but rather in the morning and in the
evening.
o TID does not mean every 8 hours but rather that three times during the
awake hours the medication would be given – in the morning, mid-day,
and evening.
o QID does not mean every 6 hours but rather the medication should be
given at approximately equal lengths of time apart 4 times during the
normal awake time. This would be during the hours from the normal
waking times of 6 or 7 am and the normal going to bed hours which are
generally 8 to 10 pm.
6 | JJustad, MD, DDP September 2019
• If a medication is written as 2 qd or 3 qd that does not mean one tablet twice daily
(BID) or three times daily (TID) but means that 2 tablets are given together once
during that day (2 qd) or 3 tablets are given together once during that day (3 qd).
• Medications may be prescribed for every 4 hours or every 6 hours or at other
intervals. Unless the prescription indicates that this only refers to when the
person is awake which would be written “while awake”, then you will need to
awaken that person to give the medication at the correct time.
The most frequently used dosing times for BID, TID, and QID or q am and q pm or hs medications.
Abbreviation
AM
Daytime hours
Daytime hours
PM
BID
6, 7, 8 6, 7, 8
TID
6, 7
12, 1
7, 8
QID
6, 7
11, 12
3, 4
8
q am 6, 7
q pm
5, 6, 7
q hs
7, 8, 9
The most frequently used dosing times for specific interval hours of administration.
q 6 hrs – or – every 6 hours
6 am, 12 noon, 6 pm, midnight – or –
7 am, 1 pm, 7 pm, 1 am
q 8 hrs – or – every 8 hours
6 am, 2 pm, 10 pm – or –
7 am, 3 pm, 11 pm
Note: “q” means “every” so “q am” would mean every morning. However, when a
medication is ordered for only certain days of the week, then the “q am” more
accurately refers to “every morning” or “in the morning” on those days that it is
ordered. So “q am twice weekly” would translate to “in the morning twice a week” or
“in the morning on Monday and Thursday”, etc.
The most frequently used schedules for intermittent medication dosing during the week.
2/wk. or 2 x per week –
or twice weekly, etc.
Monday and Thursday – or –
Tuesday and Friday – or –
Wednesday and Saturday or Sunday
3/wk. or 3 x per week – or –
3 times weekly, etc.
Monday, Wednesday and Friday (MWF) – or –
Tuesday, Thursday, and Saturday or Sunday (TThS)
4/wk. or 4 x per week – or –
4 times weekly, etc.
Saturday, Sunday, Tuesday, Thursday (SSTTh)
The Provider for whom you work should have these intervals defined so that there is no
confusion as to when medications are to be given. This ensures that each employee gives
medications at the same times during the day and on the same days of the week as
ordered.
7 | JJustad, MD, DDP September 2019
4. Step-by-step: FILLING OUT THE MAR
Davis and Hartman Medical Group, PLLC
1011 Jackson
Helena, MT 59601
406-442-6779
Date: January 3, 2015
Name: Joe Smith
Birthdate: 11/16/58
Rx:
Allegra 60 mg
Sig: one tablet po BID
Disp: 60
Refill x 1 year
Zithromax 250 mg
Sig: two tabs po today, then one tablet po qd until gone
Disp: 6
Signed: Ron Davis, MD
Ron Davis, MD
Using the prescription from Example # 1 above, you will start to fill out the MAR in a
stepwise fashion.
1. Medication # 1: Allegra, dose = 60 mg. This is written under the “medication” column.
Medication
Jan
HR
1
2
3
4
5
6
7
8
9
10
Allegra
start
60 mg
2. The instructions (or “sig”) are “one tab po bid” – this means: one tablet my mouth
twice daily. Those instructions are also transcribed into the first column.
Medication
Jan
HR
1
2
3
4
5
6
7
8
9
10
Allegra
start
60 mg, one tablet
by mouth
twice daily
8 | JJustad, MD, DDP September 2019
3. Next determine the start date. Under the column marked “Jan” for January, you
would write 1/3/15 as the start date. This is because:
a. the prescription date is January 3
rd
b. you have picked up the medication on the afternoon so there is no reason
for the person not to take the first dose of medication on that day
c. there are no specific instructions on the prescription that state to start the
medication on another day.
4. Fill in the “HR” or hour(s) that the medication is to be taken. For this example,
use 7 am and 7 pm.
Medication
Jan
HR
1
2
3
4
5
6
7
8
9
10
Allegra
start
7 am
60 mg, one tablet
1/3/15
by mouth
7 pm
twice daily
5. Next, fill in the areas that are blocked off because these are the dates that have
passed before the medication was ordered. Since the medication started on
January 3, each day prior to that is blocked off with an “X” or lined through to
show that the medication was not given on those dates. In this case on
January 1 and 2. The “open” dates, with open boxes, start on January 3, in the
evening since you picked up the medication on the afternoon of January 3.
These open boxes are used for staff to fill in with their initials (IN). Each MAR
has a place for staff to write their name and initials so that anyone could
determine which staff person gave medications on a specific date.
6. Since no “stop date” was written on the prescription, the medication will be
given every day in January and continue during the following months until it is
discontinued thus all the boxes after the medication has started are open.
Medication
Jan
HR
1
2
3
4
5
6
7
8
9
10
Allegra
start
7 am
X
X
X
60 mg, one tablet
1/3/15
by mouth
7 pm
X
X
twice daily
9 | JJustad, MD, DDP September 2019
7. Next, Zithromax. Since this is given in two different ways (2 tablets today, and
one tablet daily until gone) you must write the medication and dose in two
separate boxes.
Medication
Jan
HR
1
2
3
4
5
6
7
8
9
10
Zithromax
start
250 mg
Zithromax
250 mg
8. Zithromax has two instructions for dosing: give two tabs po today, then one tab po
qd until gone.
a. Under the first Zithromax line you would write in the first dose which is “2
tablets by mouth today”.
b. On the second Zithromax line you would write the second set of
directions which is “1 tablet by mouth daily until gone”.
Medication
Jan
HR
1
2
3
4
5
6
7
8
9
10
Zithromax
start
250 mg
2 tablets by mouth
today, then
Zithromax
250 mg
1 tablet by mouth
daily until gone
10 | JJustad, MD, DDP September 2019
9. Next write the start dates:
a. Since the first set of dosing instructions states “today” you would put
1/3/15 as the start date.
b. The second set of dosing instructions states “then one tablet daily until
gone” which means that you would give the second dose (one tablet)
starting on January 4
th
.
Medication
Jan
HR
1
2
3
4
5
6
7
8
9
10
Zithromax
start
250 mg
1/3/15
2 tablets by mouth
today, then
Zithromax
start
250 mg
1/4/15
1 tablet by mouth
daily until gone
10. Fill in the hour (HR) or times that the medication would be given:
a. For the first dose of Zithromax you are going to give it today as
instructed. To determine a time, look at the information provided which
states that the medication was picked up at 2 pm. Having the person
take the medication at 3 pm would be reasonable but waiting until the
evening medications are taken at 7 pm is another possibility. In most
cases with an antibiotic, you would want that person to have the first
dose as soon as possible.
b. The remaining doses of Zithromax are given daily. This generally
means that the medication is generally taken every morning so 7
am is an appropriate time. However, giving it at 3 pm, just as the
first dose was given, would not be wrong either.
Medication
Jan
HR
1
2
3
4
5
6
7
8
9
10
Zithromax
start
3 pm
250 mg
1/3/15
2 tablets by mouth
today, then
Zithromax
start
7 am
250 mg
1/4/15
1 tablet by mouth
daily until gone
11 | JJustad, MD, DDP September 2019
11. Block out the days the medication is not to be taken.
a. Zithromax, 2 tablets are taken only on January 3
rd
so all boxes up to and
after January 3
rd
are crossed out or have a line drawn through them.
b. Zithromax, 1 tablet daily is given “until gone”. Looking at the prescription,
you see that 6 tablets were dispensed. 2 tablets were used on the first day
so there are 4 tablets remaining which means that the medication is given
for 4 more days starting on January 4
th
. All boxes before January 4
th
and
after January 7
th
are crossed out.
c. Since this medication is given for a short time you can also put in a stop
date if desired.
Medication
Jan
HR
1
2
3
4
5
6
7
8
9
10
Zithromax
start
3 pm
X
X
X
X
X
X
X
X
X
250 mg
1/3/15
2 tablets
by mouth today
Zithromax
start
7 am
X
X
X
X
X
X
250 mg
1/4/15
1 tablet by mouth
stop
daily until gone
1/7/15
Another possible way to fill out a MAR such as this when Zithromax, or any drug, is
given for only a certain number of days (4 more days in this case) would be to place a
number (1 through 4 for this prescription) beneath the open boxes. This can act as a
double check when giving a medication for a limited number of days.
Medication
Jan
HR
1
2
3
4
5
6
7
8
9
10
Zithromax
start
3 pm
X
X
X
X
X
X
X
X
X
250 mg
1/3/15
2 tablets
by mouth today
Zithromax
start
7 am
X
X
X
X
X
X
250 mg
1/4/15
1
2
3
4
1 tablet by mouth
stop
daily until gone
1/7/15
12 | JJustad, MD, DDP September 2019
Below is the complete MAR for the two medications prescribed on January 3 and
shows that the first dose of Zithromax was given by George Peters. The MAR also
contains the diagnoses and allergies as well as name of the client and physician.
Medication Administration Record
Medication
Jan
HR
1
2
3
4
5
6
7
8
9
10
Allegra
start
7 am
X
X
X
60 mg, one tablet
1/3/15
by mouth
7 pm
X
X
twice daily
Zithromax
start
3 pm
X
X
gp
X
X
X
X
X
X
X
250 mg
1/3/15
2 tablets
by mouth today
Zithromax
start
7 am
X
X
X
X
X
X
250 mg
1/4/15
1
2
3
4
1 tablet by mouth
stop
daily until gone
1/7/15
Diagnosis: allergic rhinitis, bronchitis
Allergies:
Penicillin
IN
Name:
IN
Name:
Name:
Physician:
Phone #
NR
Noel Ranger
HT
Hillary Thomas
John Smith
Ron Davis
442-6779
gp
George Peters
DOB: 11/16/58
13 | JJustad, MD, DDP September 2019
Example # 2:
Carol is having problems with constipation so when she sees Dr. Davis on Monday
afternoon for a regular follow up appointment, you inform him of this problem. He writes a
new prescription for her. After you pick up the prescription, you fill out the MAR using the
information provided, making sure the prescription and pharmacy information matches.
Carol has no allergies.
Davis and Hartman Medical Group, PLLC
1011 Jackson, Helena, MT 59604
406-442-6779
Date: March 2, 2015
Name: Carol Potter
Birthdate: 4/10/85
Rx:
MiraLax 17 grams mixed with 8 oz fluid
Sig: give po q am twice weekly
Disp: one month supply
Refill x 11
Signed: Ron Davis, MD
Ron Davis, MD
1. Start with the medication “MiraLax”
a.
This time the instructions state that it is mixed with fluid, so those
instructions must be added to the MAR also.
Medication
March
HR
1
2
3
4
5
6
7
8
9
10
MiraLax 17 grams mixed
start
with 8 ounces of fluid
2. Next, it states to “give po” which translates into taking orally or by mouth so write
that on the MAR.
3. Add how often/when it is to be taken:
a.
q am or “every morning” or more accurately in this case “in the
morning” (on the two days a week it is given) so you could use 7 am
b.
twice weekly or twice a week
14 | JJustad, MD, DDP September 2019
Medication
March
HR
1
2
3
4
5
6
7
8
9
10
MiraLax 17 grams mixed
start
with 8 ounces of fluid
by mouth every morning
twice a week
4. Next you need to figure out the start date and which days of the week it is taken.
a.
The information provided states that it is “Monday”
b.
The medication is to be taken in the morning so that means it cannot
be taken today but would wait until tomorrow morning, Tuesday.
c.
It is to be taken twice a week so if it starts on Tuesday, taking it
on Tuesday and Friday would be reasonable.
d.
From the prescription which was written on March 2
nd
(and which you
were told is Monday), you would then know that Tuesday is March 3
rd
therefore, you would “X” out the boxes prior to that date and then “X” out every
box that is not a Tuesday or a Friday. You can also write M,T,W, etc. below the
date on the top line to help keep it straight as to the day of week the
medication is taken. In cases such as this it is ok to put abbreviations for the
day of the week as it is simply a reminder.
Medication
March
HR
1
S
2
M
3
T
4
W
5
Th
6
F
7
S
8
S
9
M
10
T
MiraLax 17 grams mixed
start
7am
X
X
X
X
X
X
X
with 8 ounces of fluid
3/3/15
by mouth every morning
twice a week
After filling in the diagnosis and the allergies, the completed MAR would appear as
below.
Medication
March
HR
1
S
2
M
3
T
4
W
5
Th
6
F
7
S
8
S
9
M
10
T
MiraLax 17 grams mixed
start
7am
X
X
X
X
X
X
X
with 8 ounces of fluid
3/3/15
by mouth every morning
twice a week
Diagnosis:
constipation
Allergies:
None
IN
Name:
IN
Name:
Name:
Physician:
Phone #
NR
Noel Ranger
HT
Hillary Thomas
Carol Potter
Ron Davis
442-6779
gp
George Peters
DOB: 4/10/85
15 | JJustad, MD, DDP September 2019
Example # 3:
Brian was seen by Dr. Davis for follow up of his atrial fibrillation. Brian’s protime/INR result
show that an adjustment in his dose of warfarin is required. A protime or INR is a blood test
which monitors the amount of warfarin that someone requires. His current dose is 3 mg
daily. To fill out the MAR you will need to know that February 6
th
is a Wednesday. You pick
up the prescription at 4 pm and fill out the MAR. Brian has allergies to shellfish and
Penicillin.
Davis and Hartman Medical Group, PLLC
1011 Jackson, Helena, MT 59604
406-442-6779
February 5, 2015
Name: Brian Hunter
DOB: 1/3/40
Rx:
Dose change:
Warfarin 1 mg
Sig: 2 tabs po q 2 pm M, W, F and 3 tabs q 2 pm S, S, T, Th for atrial fibrillation
Start tomorrow.
Disp: one month supply
Refill x 11
Signed:
Ron Davis, MD
Ron Davis, MD
1. Since this is a dose change, you must first cross out the remaining days on the
current MAR. The warfarin is currently being taken by Brian at 3 mg (or three 1 mg
tablets) daily and the days that he has taken it are already initialed. Since the
medication was picked up at 4 pm and it is to start “tomorrow”, today’s dose has
already been taken. Since there is a new dose starting on the 6
th
, all boxes after
today are crossed out and a stop date (the date the last dose was taken) is added.
Medication
February
HR
1
2
3
4
5
6
7
8
9
10
11
12
Warfarin 1 mg
start
2 pm
nr
nr
nr
nr
nr
X
X
X
X
X
X
X
3 tablets
8/4/07
by mouth
stop
daily
2/5/15
16 | JJustad, MD, DDP September 2019
2. Next you look at the new instructions for giving warfarin. There are two different
doses for the same drug, so you will need to use two separate medication lines.
a.
The first instruction is: 2 tablets po q M,W,F. This means that two 1 mg
tablets are to be taken each week on Monday, Wednesday, and Friday.
b.
The prescription was written on February 5
th
with instructions to start the new
dosing schedule “tomorrow” which would be February 6
th
. You were also told that
the 6
th
is a Wednesday therefore you know that the two 1 mg tablets start on the 6
th
and would also be taken on the 8
th
, and 11
th
.
c.
This dose of medication is not given on Saturday, Sunday, Tuesday, or
Thursday so those days which correspond to February 7, 9, 10, and 12
are crossed out.
d.
2 pm was written on the prescription as the time.
Medication
February
HR
1
2
3
4
5
6
7
8
9
10
11
12
Warfarin 1 mg, 2 tablets
start
2 pm
X
X
X
X
X
X
X
X
X
by mouth on Monday,
2/6/15
Wednesday and
Friday
3. It may be easier to fill out and read the MAR when a medication is given on
specific days of the week by writing the day of the week beneath the date.
These notations can be abbreviated. For example:
Medication February HR 1 2 3 4 5
6
W
7
Th
8
F
9
S
10
S
11
M
12
T
Warfarin 1 mg, 2 tablets
start
2 pm
X X X X X X X X X
by mouth on Monday,
2/6/15
Wednesday and
Friday
17 | JJustad, MD, DDP September 2019
4. Next look at the second set of instructions:
a. 3 tablets po q S,S,T,Th which means to take three 1 mg tablets on
Saturday, Sunday, Tuesday, and Thursday each week.
b. The start date for this dosing schedule would be February 7
th
.
c. All dates prior to starting this dosing schedule, i.e. February 1 through 6
would be X’d or lined out. Also Friday and Monday (the 8
th
and 11
th
) would
be X’d out as those are the days that 2 tablets are taken.
Medication February HR 1 2 3 4 5
6
W
7
Th
8
F
9
S
10
S
11
M
12
T
Warfarin 1 mg, 2 tablets
start
2 pm
X
X
X
X
X
X
X
X
X
by mouth on Monday,
2/6/15
Wednesday and
Friday
Warfarin 1 mg, 3 tablets
start
2 pm
X
X
X
X
X
X
X
X
by mouth on Saturday,
2/7/15
Sunday, Tuesday,
and Thursday
5. From the information provided, you know that the diagnosis is atrial fibrillation so
make sure that is written in the appropriate spot. You were also given Brian’s
allergies which should be written in the allergy section of the MAR.
The completed MAR would appear as follows:
Medication
Feb
HR
1 2 3 4 5
6
W
7
Th
8
F
9
S
10
S
11
M
12
T
Warfarin 1 mg
start
2 pm
nr
nr
nr
nr
nr
X
X
X
X
X
X
X
3 tablets
8/4/07
by mouth
stop
daily
2/5/15
Warfarin 1 mg, 2 tablets
start
2 pm
X
X
X
X
X
X
X
X
X
by mouth on Monday,
2/6/15
Wednesday and
Friday
Warfarin 1 mg, 3 tablets
start
2 pm
X
X
X
X
X
X
X
X
by mouth on Saturday,
2/7/15
Sunday, Tuesday,
and Thursday
Diagnosis: atrial fibrillation
Allergies: Shellfish, penicillin IN Name: IN Name:
Brian Hunter
Dr Ron Davis
nr Nan Rogers TJ Tim Jacobs
DOB: 1/3/40
Phone: 442-6779
CP Carol Peters
18 | JJustad, MD, DDP September 2019
Example # 4:
Caleb Harris has seizures. He saw Dr. Davis on the afternoon of February 1
st
and was
prescribed a new medication, Depakote. You pick up the medication. When you get to
the group home, you first compare the medication you picked up to your copy of the
prescription to make sure they match. You then transcribe the new medication onto the
MAR. Caleb is allergic to Tegretol and Penicillin.
Davis and Hartman Medical Group, PLLC
1011 Jackson, Helena, MT 59604
406-442-6779
Date: February 1, 2015
Name: Caleb Harris
Birthdate: 4/10/82
Rx:
Depakote 500 mg
Sig: one tab po q am for 1 week, then BID
Disp: one month supply
Refill x 11
Signed: Ron Davis, MD
Ron Davis, MD
Once again, there is one medication but two dosing schedules, so you will need to write
out the medication information twice.
1.
Start by writing out the medication name on each of two lines.
Medication
February
HR
1
2
3
4
5
6
7
8
9
10
11
12
Depakote 500 mg
start
Depakote 500 mg
start
19 | JJustad, MD, DDP September 2019
2.
Then write out each set of directions. Remember to always write out the route
for the medication as well as how often it is taken in one day and how long the
medication should be taken before stopping it. If there is no indication of a stop
date such as the prescription stating: “for 1 week”, then assume the medication
is to be taken indefinitely or at least until a new order is received.
Medication February HR 1 2 3 4 5 6 7 8 9 10 11 12
Depakote 500 mg
start
1 tablet by mouth
every morning for
one week, then
Depakote 500 mg
start
1 tablet by mouth
twice daily
3.
Next determine the start date for each dose.
a.
Since for the first week, it is to be given in the morning only, you would start
the following day – February 2
nd
as the appointment was on the afternoon
of February 1
st
.
b.
The twice daily dosing starts one week (7 days) later so the starting date
would be February 9
th
.
c.
Also write in the hour that it is to be given. Every morning is usually at 6, 7,
or 8 am. BID is 6 & 6, 7 & 7, 8 & 8, or combinations of these times. For this
example, we will use 7 am and 8 pm.
Medication February HR 1 2 3 4 5 6 7 8 9 10 11 12
Depakote 500 mg
start
7 am
1 tablet by mouth
2/2/15
every morning for
one week, then
Depakote 500 mg
start
7 am
1 tablet by mouth
2/9/15
twice daily
8 pm
20 | JJustad, MD, DDP September 2019
4.
Now “X” or line out the days prior to the start date for each dosing schedule and
also “X” or line out the days following the one week of the medication is taken in
the morning only. You can also put in a stop date for the once daily dose.
Medication
February
HR
1
2
3
4
5
6
7
8
9
10
11
12
Depakote 500 mg
start
7 am
X
X
X
X
X
1 tablet by mouth
2/2/15
every morning for
stop
one week, then
2/8/15
Depakote 500 mg
start
7 am
X
X
X
X
X
X
X
X
1 tablet by mouth
2/9/15
twice daily
8 pm
X
X
X
X
X
X
X
X
The completed MAR would appear as below:
Medication
February
HR
1
2
3
4
5
6
7
8
9
10
11
12
Depakote 500 mg
start
7 am
X X X X X
1 tablet by mouth
2/2/15
every morning for
stop
one week, then
2/8/15
Depakote 500 mg
start
7 am
X
X
X
X
X
X
X
X
1 tablet by mouth
2/9/15
twice daily
8 pm
X
X
X
X
X
X
X
X
Diagnosis:
seizures
Allergies:
Shellfish, penicillin
IN Name: IN Name:
Caleb Harris
Dr Ron Davis
nr Nan Rogers TJ Tim Jacobs
DOB: 4/10/82
Phone: 442-6779
CP Carol Peters
21 | JJustad, MD, DDP September 2019
Giving or Applying Medication
A. The person giving or applying a medication should know and consider the following:
Why the medication is being given and the expected result
Potential side-effects and precautions to take
B. The Seven Rights of Medication Delivery must be followed for every medication that
is given:
1. Right Individual or Person
2. Right Medication
3. Right Dose
4. Right Time and Date
5. Right Route
6. Right Position
7. Right Form (meaning consistency, texture such as crushed, mixed with food)
C. Stay with the person until the medication is taken and make sure that it is swallowed
(if an oral medication). You cannot document that a medication was taken
unless you see that it was swallowed or applied, etc.
D. Medications are to be given and documented by the person who prepared the
dose(s).
NEVER given any medication set up by another person
Give ONLY medications you personally have set up
E. Give medications only from containers:
that have an intact pharmacy label if it is a prescription drug
that have a manufacturer’s intact label if it is a non-prescription drug
22 | JJustad, MD, DDP September 2019
The First 8 Steps for Medication Administration
These apply to all medications regardless of the route given and must be
done EVERY TIME for EVERY MEDICATION.
1. Wash hands
2. Start at the beginning of the medication administration record (MAR) and review,
checking for the following:
a. Individual’s name
b. All medications ordered
c. Medications to be given now
d. Confirm that the previous dose was given
e. Confirm that the dose for this time has not yet been given
f. Any allergies
g. Special instructions for giving the medication
3. Read the MAR to confirm the entire drug name (including strength) and the dose
(amount) of medication you will be assisting with at this time.
4. Get the medication from the secure storage area.
5. Read the entire label carefully including the expiration date and special instructions.
Make sure the description of the drug matches the drug inside the container.
6. The first check of the MAR to drug label:
a. Place the medication container beside the name of the drug on the MAR
b. Make sure the container and the MAR match exactly
c. Confirm the first 5 Rights (Person, Medication, Dose, Time, Route)
7. The second check of the MAR to label is a repeat of the first check:
a. Place the medication container beside the name of the drug on the MAR
b. Make sure the container and the MAR match exactly
c. Confirm the first 5 Rights (Person, Medication, Dose, Time, Route)
8. If they do not match, do not give the medication until there is clarification from
a healthcare record or healthcare professional regarding the medication. If they do
match, go to the instructions for giving medications according to the type of
medication or route taken.
Use of the optional “dot system”
The “dot system” provides a means of tracking medications as they are prepared and
assists with documentation after administration. The use of the “dot system” is an optional
addition to the steps for administering medications.
The use of the “dot” is an additional step following the 3
rd
MAR check during preparation of
medications. To use the “dot system”:
23 | JJustad, MD, DDP September 2019
• When you complete the 3
rd
MAR check, a “dot” is placed in the space on the MAR
where you will initial to document the administration of the medication after the client
has swallowed it or it has otherwise been given, applied, etc.
• The “dot” indicates that all 3 MAR checks have been done and that the medication is
ready for giving.
Using the dot system as part of the 3
rd
MAR check:
1. The third check is done for each medication as it is placed in the cup for oral
medications and while making sure you have the right medication for other forms of
medications.
a. Check the medication label against the MAR
b. Check the amount of medication in the cup to make sure it matches the label
and the MAR
2. Mark a dot in the space on the MAR where you will document the
administration of the medication after having given it.
Medication start August 1 2 3 4 5 6 7 8 9 10 11 12 13
Lisinopril 10 mg
6/1/17
8 am
jk
jk
jk
jk
˖
one tablet by
mouth daily
↑
The “dot” is a visual assist in identification of the prepared and administered medications.
3. Following the administration of the medication(s), you will then place your
initials in the space for that specific medication which documents that you have
given the right medication, right dose, to the right individual at the right time using the
right route with the person in the right position and the right consistency (if indicated).
Medication start August 1 2 3 4 5 6 7 8 9 10 11 12 13
Lisinopril 10 mg
6/1/17
8 am
jk
jk
jk
jk
NR
one tablet by
mouth daily
4. If the medication was prepared, but not given, you would document this by initialing
the MAR, circling your initials, and writing an explanation on the back of the MAR.
You would also write an incident report.
5. It is NEVER appropriate to place your initials on the MAR before the medication has
been administered (and if an oral medication, you have seen that it was swallowed).
Documentation of medication administration that has not yet been given not only
compromises the safety of the individual, but it is also falsification of a legal
document which is a prosecutable offense.
