Medication recording and medication competency assessments
When a medication administration record (MAR) is required
A MAR is required to formally record any medication support including 'over the counter medication' and medication that is prescribed on a PRN (Latin phrase for 'pro re nata') meaning "when required" basis and in accordance with Kirklees providers Contract that states; 'Medication Record Sheets must be completed for Service Users who require any level of support with medication'.
The provider must ensure a MAR is in the service user's home or available and accessible to staff electronically before supporting them with their medication.
Information that needs to be considered and included on a MAR
MAR's should evidence the six 'R's of medication are being followed:
- Right person
- Right medicine
- Right route, for example, Oral/Topical
- Right dose
- Right time
- Right to refuse
All MAR's should include the following information:
- Service username, address and date of birth
- GP name, practice contact details
- Pharmacy contact details
- District nurse name, practice and phone number. (If applicable)
- Medication allergies/intolerances
- Start date
- Name of each medication recorded separately (it is not acceptable by the Council or CQC to write 'Multi-Compartment Compliance Aid' (sometimes known as a dosette) as this does not necessarily evidence the provider is following all of the 6 'R's)
- Form of medication, for example, tablet, capsule, liquid, eye drops or topical cream. (Including a description about how much and where to apply creams needs to be recorded)
- Route, for example, taken orally, via PEG, applied to skin etc.
- Strength/Dosage (Pay attention to milligrams/micrograms)
- Frequency and time (include any specific interval times if applicable)
- Duration (if applicable)
- Any special storage instructions for example, store in refrigerator
- Any other special instructions for example, 'take with food', 'dissolve in water'
- Any advice label or warnings for example, 'may cause drowsiness' that cannot fit on the MAR should be highlighted on the MAR by adding 'see risk assessment.'
Medication Records can be used as evidence of an investigation or in legal court cases.
Any MAR either available in the home or an electronic version should be:
- Correct
- Up to date
- Legible
- Recorded in ink and not in pencil
- Clearly numbered if there is more than one MAR for each month. Each MAR should be numbered and marked on the front 1 of 2, 2 of 2 etc.
Transcribing onto a service users MAR
Transcribing medication is the action of copying details of prescribed medication onto the MAR's from the following sources:
- An original prescription
- A printed or written record obtained from the service user's GP detailing current prescribed medication
- The pharmacy label on the medicine container or box
Printed MAR's from a pharmacist have less risk of errors that can be caused due to:
- Clerical error - incorrectly transcribing the medication/prescription details.
- Handwriting that is difficult to read and can be misunderstood.
Ideally printed MAR's provided by the service user's pharmacist should be in place. This is recommended by Kirklees Contract Team and 'NICE guidance' for all service users who require medication support from a provider. However, it is not a legal requirement for a pharmacist to provide a MAR.
If the service user's pharmacist does not supply a printed MAR the provider may deem it necessary to discuss with the service user, the benefits of a printed MAR and seek their permission to change their pharmacist to one who will provide a printed MAR.
It is the responsibility of the provider when supporting a service user with medication/s to ensure that there is an up-to-date MAR in place and that safe practice and procedures are used to support with all medications.
If the provider is required to transcribe the service user's medication details onto a MAR, they will need to ensure the service user's MAR is transcribed by a senior member of staff appropriately trained and competency assessed, to be able to transcribe medications.
Transcribing onto a MAR is NOT to be done by staff unless they have been trained and competently assessed in transcribing medications.
It is strongly recommended that staff only record on MAR's from a pharmacy, qualified health care professional or the provider they are employed to work for. They must not use a MAR that has been transcribed by anyone else, including service user families or another provider. (Also see Kirklees Protocol for Shared Packages).
What to do if there are changes to medications after a MAR has been put in place
Staff must immediately inform their line manager as soon as they become aware of any changes to the service user's medication or prescription made by a health professional such as the GP or Consultant. Changes may include dosage, frequency, a medication may have been stopped, or additional medication may have been prescribed (e.g., Antibiotics).
The provider must ensure any changes are recorded and should request verification from the prescriber to evidence what is required, from when this is to start and for how long. A copy of any documents or verbal response must be retained with the service user's records.
In general, staff must not support with medications without the correct MAR being in place. However, sometimes there are changes that occur to a service user's medication after the MAR has been put in place. It is recognised that it is not always possible for a senior, competently trained member of staff to be immediately available to go to the service user's home to amend the MAR. In these circumstances staff must discuss the changes with a competent senior member of staff before supporting with medication changes. It is the responsibility of the provider to ensure support and advice is offered to staff to ensure they are confident and feel competent to correctly support the service user with their medication changes. If staff do not feel confident or competent and the provider is unable to be sure the 6 'R's are able to be followed by staff, the senior person must ensure a competent person assists to support the service user with their medication and change the MAR accordingly. In cases where manager has deemed it necessary for staff to support with medication without a MAR in place, then the staff MUST make a record in the DAILY RECORDS of the medication support they have provided. The records MUST include the name of the medication, the form of medication (e.g., tablet, capsule, cream) the route, for example; taken orally, PEG feeding, applied to skin, strength and dosage (Pay attention to milligrams/micrograms) and the time.
Important considerations for staff supporting with medications and recording on MAR
Staff should always:
- check the service users support/care plan for confirmation of the medication support required for a service user before supporting with medication
- read and follow instructions on the MAR each time they support a service user with their medication. They must do this before providing medication support to reduce any potential and associated risks to the service user and themselves
- check the MAR details against the medication bottles and packets to ensure they are the same, before supporting with medications. (If the medication is supplied in its original packaging).
- gather all the equipment needed to administer/support with the medication such as 5ml spoon, MAR chart, gloves etc. before supporting with medication
- write the opening date on the packaging of any medication that has a 'use within' period on e.g., 'use within 6 weeks of opening.' Also, check there is a start and end date recorded on each Multi-Compartment Compliance Aid this is particularly important if there is more than one Multi-Compartment Compliance Aid
- ensure they never use any medication if dates or use within time periods have expired. (If the date has expired the service user's medication must not be given or supported with. Staff must immediately inform their line manager who must then immediately inform the prescriber or person who is responsible for ordering the service user's prescriptions to ensure a replacement is provided)
- ask the service user if they have taken any medication already, checking the MAR to ensure that none of the medicines have already been given/signed for. (If there is reason to believe the service user has already had their medication then STOP THE PROCEDURE and inform the line manager)
- check the MAR and labels for any special instructions before supporting with any medication for example, does it need to be taken before or after food? Should the service user avoid alcoholic drink? Does the medicine need to be dissolved or mixed with water before taking? Should it be swallowed whole not chewed? Ensure that additional instructions are followed
- sign the MAR under the correct date/time immediately after supporting a service user with their mediation
- ensure any errors made when signing the MAR are not obliterated by scribbling through with a pen or using Tippex. Errors should be crossed through with a single line and initialled by the person who made the error, then an explanation of why the error was made, recorded on the back of MAR chart. All errors must be reported immediately to a line manager.
- sign only for medicines they have supported with and must not sign for medicines given by others.
- ensure that for any prescribed medicine not given/taken/applied must be clearly recorded on the MAR using the correct code, for example, 'R' for medication refused and also record more detailed explanation on the back, or in the notes section of the MAR, or in the daily records if there is no room on the MAR, and report immediately to a senior person in charge.
Recording on a MAR where there are shared packages
Brokerage will always try to place a service user with the same provider for all aspects of their assessed support, especially medication support. Risks are increased if more than one provider or provider and relatives are supporting service users with their medications. However, it is not always possible to have the same provider.
Where it is not possible to have the same provider supporting the service user and medication support is required, all providers should use and complete their own MAR.
Providers must check each other's MARs and daily records before any support is provided to ensure no issues have been recorded and that there are sufficient gaps between the time of the last medication and the due medication, for example, a gap of 4 hours is usually required between medications.
If there is reason to believe the service user has already had their medication, staff must STOP THE PROCEDURE and inform their line manager.
All providers must share Kirklees Council's 'Shared protocol' with staff so they can ensure the protocol is followed. A copy is available from the Contracts team if necessary.
Other people, including relatives, and health care professionals who may support with medication should also be encouraged by the assessor or provider to check any MAR's before supporting with medication and should make an entry on the MAR or the daily records to show when they have supported with medication and to minimise mistakes being made. E.g too much medication being taken/too much cream being applied, including steroid creams that can be harmful if too much is applied.
Further guidance
Managing medicines for adults receiving social care in the community | Guidance | NICE