MEDICINES MANAGEMENT STANDARD OPERATING PROCEDURE (MMSOP018) Preparation of Medication Administration Record (MAR) Charts

Transcription

1 MEDICINES MANAGEMENT STANDARD OPERATING PROCEDURE (MMSOP018) Preparation of Medication Administration Record (MAR) Charts Any deviation in practice from this procedure must be discussed with the Community Health Services Pharmacist Scope Staff Group Responsibility Aim All settings where staff prepare MAR charts. Registered nurses (RN), pharmacy staff, doctors. Trust Care Co-ordinators (Band 4/5) who are trained and competent It is the responsibility of this staff group to act in accordance with the Medicines Management Policy and this procedure To inform this staff group of the procedure for preparation of MAR charts Local Details This section must be completed by the Clinical Manager. If details change, a new SOP should be completed and the previous copy archived. Location Location of electronic MAR chart template.. Location of blank paper MAR charts.. Local details completed by... Date.. Monitoring Version 3 Description of Change Document Control Incidents will be monitored via Datix Staff Group: Designated Extra Care staff removed Number 6: Added advice on injections given by registered nurses Date March 2015 Review date March 2017 Version 3 Authors G. Ascough, S. Woodley, Community Health Services Pharmacists P. Scrimshaw, Specialist Pharmacy Technician (V2) Approved by Senior Pharmacists Group on 17 th March 2015 MMSOP for Preparation of Medication Administration Record (MAR) Charts V3 Review date: March 2017 Page 1 of 5

2 Procedure MAR charts are used by domiciliary care workers providing Level 2 assistance with medication in which the care worker administers the medicines to the service user. See DN230 Medicines Management in Domiciliary Settings (Adults) Policy. MAR charts are not required for Level 1 assistance (where the care worker reminds or prompts the service user but does not administer the medicines) or for service users with monitored dosage systems. Before preparing a MAR Chart 1. Obtain a list of currently prescribed medicines. 2. If necessary, contact the prescriber: To review the medicines if the frequency of carer s visits do not correspond with the frequency of administration of medicines. Where instructions, dose, timing, frequency or any other aspect of the service user s medication is unclear. To decide the actual dose to be given where a dose range is prescribed and the service user will be unable to decide which dose they require (the carer can not make this decision). To review as required medicines and establish whether they need to be included on the MAR chart. If the service user is unable to decide whether they need the medicine it should not be included as the carer cannot make this decision for them. Preparing the MAR Chart(s) 3. Complete the MAR chart(s) in indelible ink, either on a computer or clearly by hand. For examples of how to complete the medicine details see pages 3,4 & 5 (includes warfarin, weekly medicines, short courses, as required, reducing doses etc) 4. Fully complete all details relating to the service user and medicines. Add any additional instructions or information relating to the medicines that will help to inform the carer. 5. Ensure that the details are wholly consistent with the label on the medicine and include the medicine name, form, strength and dose at the appropriate time of day to fit with medicine and carers visits. 6. Do not include medicines on the MAR chart that are to be administered by a registered nurse e.g. injections; however details can be added in the Useful Information section. e.g. District Nurse to administer insulin (but do not include full instructions of dosage etc). 7. For as required medicines: If the as required medicine is to be offered to the service user regularly at specified times, which coincide with carers visits each day, include on the MAR chart for regular medicines, clearly stating if needed for. If it is only to be given occasionally at the request of the service user, use an As Required (PRN) Medicines MAR chart. 8. Complete the number of MAR charts in use and if there are other charts in use e.g. As Required, Reducing Dose, state the number and types on each chart. 9. If the MAR chart for regular medicines starts within the last few days of the month, produce a second chart for the following month. Ensure that the correct date and month are clearly stated on both sides of all charts. 10. Sign and date the Completed by section on all charts. 11. Ask a registered nurse, member of the pharmacy staff, doctor or care co-ordinator to check the MAR chart(s) and complete the Checked by section on all charts. If discrepancies are found a new chart should be produced or the chart may be amended by hand providing this is done clearly and unambiguously. Note: In some settings e.g. a service user s home, it may not be possible to obtain a check. In this instance it is advisable to have a short mental break between producing the MAR chart and the final check for accuracy. 12. In inpatient settings file a copy of the MAR chart(s) in the patient s notes. MMSOP for Preparation of Medication Administration Record (MAR) Charts V3 Review date: March 2017 Page 2 of 5

3 Medicine Administration Record (MAR) Chart for Regular Medicines Route BREAKFAST Alendronate tab 70mg x1 MONDAYS ONLY X X X X X X X X X X X X X X X X X X X X X X X X X X Adcal D3 tab x 2 NOT on MONDAY X X X X X Aspirin dispersible tab 75mg x 1 Levothyroxine tab 100microgram x 1 Levothyroxine tab 25microgram x1 Lactulose liquid 2x5ml spoonfuls Paracetamol liquid 250mg in 5ml 20ml Isosorbide mononitrate MR tab 60mg x HALF a tablet Trimethoprim 200mg tab x1 for 7 days X X X X X X X X X X X X X X X X X X X X X X X X LUNCH Omeprazole cap 20mg x 1 Fentanyl patch 25micrograms/hr Change every 3 days Paracetamol liquid 250mg in 5ml 20ml Skin X X X X X X X X X X X X X X X X X X X X TEA Half-Sinemet Cr M/R tab x 1 Warfarin tablets as in yellow book (sign and also write dose given in mg) Paracetamol liquid 250mg in 5ml 20ml BEDTIME Paracetamol liquid 250mg in 5ml 20ml Temazepam 10mg tab x 1 If needed to sleep Hydrocortisone Cream 1% To rash on Skin leg Latanoprost eye drops 0.005% x 1 drop Eye RIGHT EYE Trimethoprim 200mg tab x1 for 7 days X X X X X X X X X X X X X X X X X X X X X X X X MMSOP for Preparation of Medication Administration Record (MAR) Charts V3 Review date: March 2017 Page 3 of 5

4 Medicine Administration Record for as required (PRN) Medicines Service Users details: Sheet 1 of... 1 (Include All MAR charts) Please complete all shaded areas before chart goes into service user s home G.P: Dr Doctor Name: Ann Patient Address: 1 High Street, Town AB1 2CD Date of Birth: Known allergies: None Known Name, form and strength of medicine: Morphine sulphate oral solution 10mg in 5ml (Oramorph) Prescribed dose, directions and reason for use: 10mg (5ml) to be taken at 4 hourly intervals if needed for breakthrough pain Minimal interval between doses: 4 hours Maximum dose in 24 hours: 6 doses Review date: 1 st April 2015 by GP (If PRN medications are given regularly it may be appropriate to inform the prescriber) Chart completed by: Chart checked by: Medication Audit Start balance End balance Quantity Date Signature Print name Date Time given Dose given Signature Print Name Quantity remaining MMSOP for Preparation of Medication Administration Record (MAR) Charts V3 Review date: March 2017 Page 4 of 5

5 Medicine Administration Record for REDUCING DOSES of medication Service Users details: Sheet of (Include All MAR charts) Please complete all shaded areas before chart goes into service user s home Name: Ann Patient G.P: Dr Doctor Address: 1 High Street, Town AB1 2CD Date of Birth: Known allergies: None Known Name, form and strength of medicine: Prednisolone 5mg EC tablets Prescribed dose and directions: Week one: 10mg (2 tablets) to be taken each morning Week two: 5mg (1 tablet) to be taken each morning Then stop. Review date or stop date: last dose on 14 th April 2015 Chart completed by: Chart checked by: Medication Audit Quantity Date Signature Print name Start balance 21 tablets 01/04/2015 End balance When to take Date Dose When to be taken 01/04/ x 5mg morning tablets 02/04/ x 5mg morning Time given Administration record Signature Print name Quantity remaining 03/04/ x 5mg morning 04/04/ x 5mg morning 05/04/ x 5mg morning 06/04/ x 5mg morning 07/04/ x 5mg morning 08/04/ x 5mg morning tablet 09/04/ x 5mg morning 10/04/ x 5mg morning 11/04/ x 5mg morning 12/04/ x 5mg morning 13/04/ x 5mg morning 14/04/ x 5mg morning 15/04/2015 Course finished MMSOP for Preparation of Medication Administration Record (MAR) Charts V3 Review date: March 2017 Page 5 of 5