MEDICAL ORDERS AND MEDICATION ADMINISTRATION RECORD (MAR)

Transcription

1 MEICAL ORER AN MEICATION AMINITRATION RECOR (MAR) The purpose of this section is to assist the learner in understanding medical orders and how to document medications, treatments and therapies on the medication administration record (MAR). KEY TERM: Medical order administration record (MAR) P.R.N. medications Parameters elf-medicate OBJECTIVE: After completing this section the learner will be able to: escribe what requires a medical order and what requires review by the resident s primary health care practitioner; emonstrate the ability to record medications on the MAR; escribe how to document a missed or refused medication; efine a PRN medication and how it must be recorded on the MAR; escribe parameters and the importance of having parameters written for PRN medications; escribe what must be documented when a resident has written approval from his or her primary health care practitioner to self-medicate.

2 MEICAL ORER AN MEICATION AMINITRATION RECOR (MAR) MEICAL ORER The AFH provider is responsible for obtaining all necessary written orders as well as understanding the reason for the medication, what the medication is expected to do and any special instructions from the prescribing practitioner about the medications. The AFH provider is responsible for carrying out the written orders. The following must all have a written medical order from a prescribing practitioner: Prescription medications; Prescribed over-the-counter (OTC) medications including vitamins and other nutritional supplements; Prescribed dietary supplements; and Prescribed treatments and therapies. OTC medications, vitamins, nutritional supplements or home remedies not prescribed but requested by the resident must be reviewed by the resident s primary health care practitioner and documented in the resident s record. Written orders from a hospital or nursing home sent with the resident can be used initially if signed by a physician or nurse practitioner. These orders must be followed up with written orders from the resident s primary health care practitioner as soon as possible.

3 Changes to medical orders may not be made without the resident s primary health care practitioner or prescribing practitioner s approval. All medical orders must be carried out as prescribed unless the resident or the legal representative refuses to consent. Refer to Chapter 1 Resident rights regarding the authority of a legal representative to make medical decisions for a resident. If a resident refuses to consent to an order, the primary health care practitioner or prescribing practitioner must be notified by the AFH provider and documented in the resident s record. Order changes Changes to medication, treatment or therapy orders obtained by telephone must be followed up with a signed order from the prescribing practitioner. When taking an order over the telephone, it must be recorded in the resident s record along with the printed name and signature of the person taking the telephone order. Requests for signed orders must be made promptly after receiving any telephone order. All attempts to request written orders must be documented in the resident s record. Changes in the dosage or frequency of an existing medication require a new pharmacy label. If a new pharmacy label is not obtained, the change must be written on the existing pharmacy label and must match the new medication order. Ensuring Quality Care

4 Original order Changed order Important note: If the prescribing instructions change regarding dosage, time and how a medication should be taken, be sure the pharmacist is informed. o not have the prescription refilled without the pharmacist contacting the prescriber for the correct information. 3 Medical Orders and Administration Record (MAR)

5 MEICATION AMINITRATION RECOR (MAR) A written medication administration record (MAR) must be kept for each resident. The MAR must be kept current at all times. Frequent changes to the dosage of some medications are common. Failure to keep the MAR up-to-date could result in a medical emergency for the resident. The MAR must identify all medications, treatments or therapies you or your staff administer including, but not limited to: Prescription medications; Over-the-counter medications; ietary supplements, including vitamins and minerals; Treatments; Vital signs; and Blood sugar checks (CBGs). Immediately after administering a medication or performing a treatment, therapy or procedure, the person doing the task must write his or her initials in the appropriate place and note any information required. Every set of initials must have a legible signature on the MAR for identification purposes. If multiple caregivers have the same two initials, decide who will need to add an initial for a middle name. Make sure there is a matching signature for every set of initials on the MAR. Write the month and year on a new MAR sheet each month. Carefully write the medication, dose, route, days and times the medications are to be administered on each resident s MAR according to the written medical orders. If you receive an order to stop a medication during the month, note that on the MAR after the last Ensuring Quality Care The MAR must be legible and clearly indicate the name of each medication, the dose, the route (how it is to be administered) if other than by mouth, and the day and time the medication must be given. 4 Medical Orders and Administration Record (MAR)

6 dose is given and draw a line to the end of the month. Example: administration record (MAR) and MAR for PRNs: PRN medications ome medications, such as those used for pain, are written as PRN. This means the medication is given as needed. AFH rules require that all PRN medications, including over-the-counter medications, have specific parameters indicating what the medication is for and specifically when, how much and how often the medication may be administered. It is best if the prescribing practitioner writes the parameters when ordering any PRN medication. It is also helpful to ask your pharmacist to request this information when accepting a prescription order over the phone. 5 Medical Orders and Administration Record (MAR)

7 If a PRN medication does not include specific written parameters, you may ask the RN to assess the resident s condition and write the parameters. RNs cannot write parameters for any medication, including OTCs and supplements, that does not have a medical order. The parameters should be recorded on the medication administration record (MAR). Any caregiver dispensing medications for that specific resident must follow these instructions. If you or one of your caregivers does not have a clear understanding of the instructions, ask the RN, pharmacist or prescribing practitioner to explain them in more detail. When giving PRN medications, you must note the time, dose, reason the medication was given, and whether or not it was effective. It is important to note on the MAR when the PRN medication was given to avoid errors in overdosing or under-dosing the resident. With up to five residents in your home, it can be challenging, but it is extremely important that you keep all of this information. It must be written on the MAR so all caregivers know when the PRN medication was given. Example: MAR with PRN medications Administration/InstructionRecord Record Administration/Instruction Resident: Ms. M.A. (list the resident s full name) Month/Year: January 2011 list the resident s healthcare practitioner s name Codeine, ulfa drugs, airy products Tylenol 325 mg 2 tables q4 hours as As needed for a needed headache Milk of Magnesia 2 tablespoons As qday if no BM for needed 3 days : ignature: Best Caregiver : ignature: aisy hift ignature ignature Ensuring Quality Care Physician: Allergies: 6 Medical Orders and Administration Record (MAR)

8 Administration Record for PRNs Resident: Ms. M.A. (list the resident s full name) Month/Year: January 2011 ate 1/2/2011 1/5/2011 1/10/2011 1/24/2011 1/29/2011 1/30/2011 Hour 10:15 am 8:00 am 3:00 pm 11:00 am 1:00 pm 8:00 am Tylenol Milk of Magnesium Tylenol Tylenol Tylenol Tylenol Physician: list resident s healthcare practitioner Allergies: Codeine, ulfa drugs, airy products c/o No c/o c/o c/o c/o Instructions A. Write initials in appropriate box at the time medication is given. B. Circle initials when medication is refused. C. tate reason for refusal in the narrative.. tate reasons PRN is given, and the results. E. ate and initial all changes. Reason of headache BM since 1/2/2011 of headache of headache of headache of headache Results No headache BM on 1/6/2011 No headache No headache No headache No headache 1 2 IX Hour 11:00 am 9:00 am 3:45 pm 11:30 am 2:15 pm 8:20 am ignature Best Caregiver Ifnx~Xm nky The caregiver giving the PRN medication also needs to document in the resident s record the response to the medication. For example: 01/02/2011 Ms. M.M.A. complained of a headache at 10 am. Gave her two Tylenol tablets at 10:15 a.m. At 11 a.m. Ms. M.M.A. reported that she no longer had a headache. 01/05/2011 Ms. M.M.A. has not had a BM for three days gave 2 tablespoons of milk of magnesia at 8 a.m. 01/06/2011 Ms. M.M.A. had a BM this morning. 7 Medical Orders and Administration Record (MAR)

9 s not scheduled every day ome prescription drugs are not given every day of the week. For example, a medication used to treat hypothyroid disease frequently is scheduled for only five days a week. Example: MAR with scheduled medications not given every day Administration/Instruction Record Administration/Instruction Record Resident: Ms. M.A. (list resident s full name) Month/Year: January 2011 list resident s healthcare practitioner Codeine, ulfa drugs, airy products L-thyroxine 125 mcg 7 1 tablet every Mon, am Tues, Thu, Fri & at Physician: Allergies: IX IX IX : ignature: Best Caregiver ignature : IX ignature: Ifnx~Xm nky ignature Ensuring Quality Care The two days of the week, Wednesday and unday, the medication is not to be given have been clearly marked out. 8 Medical Orders and Administration Record (MAR)

10 s with alternating dosing ome medications may be ordered given with two different dosages on different days. When different doses of the same drug are given on different days or different times, the drug needs to be listed on the MAR each time the dose is different. Example of MAR with alternating dosing Administration/Instruction Record Resident: Ms. M.A. (list resident s full name) Physician: list resident s healthcare practitioner Month/Year: January 2011 Allergies: Codeine, ulfa drugs, airy products L-thyroxine 125 mcg 1 tablet every Mon, Wed & Fri 7 am L-thyroxine 125 mcg 1/2 tablet every Tue, Thu, at & un 7 am : ignature: Best Caregiver ignature : ignature: aisy hift ignature L-thyroxine is given in two different doses on alternating days. Monday, Wednesday and Friday the resident is given a whole tablet. On Tuesday, Thursday, aturday and unday the resident is given a half a tablet. The days a dose of the L-thyroxine is not given must be clearly marked out. It does not matter if you use a single line, an x or shade out the day with a highlighter for the days a dose is not given; just be consistent on all MARs. o not use words that could be mistaken for initials.

11 s change If the medication dose is changed, draw a line from the last dose given to the end of the month. In a new line, write the new information regarding the medication, dose, route, day and time; draw a line to the start day. Example MAR with medication change Administration/Instruction Administration/Instruction Record Record Resident: Ms. M.A. (list resident s full name) Month/Year: January 2011 list resident s healthcare practitioner Codeine, ulfa drugs, airy products L-thyroxine 125 mcg 7 B 1 tablet every Mon, Tues, Thu, Fri & at am C L-thyroxine 125 mcg 7 1 tablet every am am Physician: Allergies: B B C C IX B C B C B IX C B IX B C C new order started on 1/17/2011 Order discontinued on 1/16/2011 B B B B B IX B B IX B B IX IX IX C C C C C C C C C : ignature: Best Caregiver ignature : IX ignature: Ifnx~Xm nky ignature Ensuring Quality Care For example, the L-thyroxine order has changed to mg given by mouth every morning. 10 Medical Orders and Administration Record (MAR) 1

12 Missed or refused medications If a medication is either missed or if the resident refuses to take it, the caregiver must document this on the MAR circling the caregiver s initials, and indicate why the medication was missed or refused. The caregiver also documents in the resident s record what action was taken (who was notified), as well as any follow-up instructions from the resident s primary health care practitioner. Example: MAR with missed or refused medication Administration/Instruction Record Administration/Instruction Record Resident: Ms. M. A. (list the residents full name) Physician: list residents healthcare practitioner Month/Year: January 2011 Allergies: Codeine, ulfa drugs, airy products Proventil 7 am 90/mcg/spray inhaler - 2 puffs thru mouth every 6 hours while awake 1 pm 7 pm : ignature: Best : IX ignature: Ifnx~Xm rky Caregiver Resident: Ms. M.A. (list the resident s full name) Month/Year: January 2011 ate Hour ignature ignature Physician: list resident s healthcare practitioner Allergies: Codeine, ulfa drugs, airy products Reason Results 01/07/11 1 pm Proventil 90 mcg spray Refused stated didn t need it No difficulty with breathing 01/15/11 1 pm Proventil 90 mcg spray Out shopping No difficulty with breathing Instructions A. Write initials in appropriate box at the time medication is given. B. Circle initials when medication is refused. C. tate reason for refusal in the narrative.. tate reasons PRN is given, and the results. E. ate and initial all changes. 1 2 IX ignature Best Caregiver Ifnx~Xm nky Medical Orders and Administration Record (MAR) Hour

13 Below are examples of documentation found on the MAR as well as in a resident s record when a medication was refused or missed: MAR: 01/07/2011 refused 1 pm Proventil inhaler. Resident Record: 01/07/2011 Ms. M.A. stated that she wasn t having any trouble breathing and didn t need the medication. I reminded the resident why she was taking the medication and why it was needed. he still refused. Notified the RN, as instructed and was told to call back if Ms. M.A. had trouble breathing or continues to refuse to take her inhaler. Best Caregiver. Resident Record: 01/07/2011 Ms. M.A. took her 7pm inhaler without complaint. id not notice any difficulties in breathing and Ms. M.A. did not complain of any difficulties. Best Caregiver. MAR: 01/16/ pm inhaler treatment missed. Resident Record: Ms. M.A. did not appear to have trouble breathing and stated she was fine. Notified the RN, as instructed, and was not given any special instructions. Ms. M.A. had 7 pm inhaler and went to bed at 10 pm without complaints of having trouble breathing. Ensuring Quality Care

14 Residents who self-medicate In the case of those residents with written authorization from their primary health care practitioner to self-medicate, you are still responsible for knowing the reason for the medication, what the medication is expected to do and if there are any special instructions from the prescribing practitioner about the medications. In order for you and your caregivers to document in the resident record that the resident is taking medications as ordered, keeping an updated MAR record is recommended. Instead of staff initialing the medication and time of day, they will need to record information in the resident s record regarding the resident s ability to take medications as prescribed. Having a MAR for each resident that selfmedicates is also necessary in an emergency when information needs to be shared with emergency responders or if the resident is unable to take medications. Example: MAR with self-medication information Administration/Instruction Administration/Instruction Record Record Resident: Ms. M.A. (list the resident s full name) Month/Year: January 2011 Physician: Allergies: list the resident s healthcare practitioner s name Codeine, ulfa drugs, airy products Multi Vit 1 tablet 7 am q am L thyroxine 125 mcg every am 7am Tylenol 325 mg 2 tablets q4 As hours as needed needed for a headache Resident has order to self-medicate all medications. ee resident record for documentation. Milk of Magnesia 2 As tablespoons needed qday if no BM for 3 days : ignature: Best Caregiver : ignature: aisy hift ignature ignature 13 Medical Orders and Administration Record (MAR)

15 Example: A completed MAR with medication change order, refused/missed medication and PRN medications Record Administration/Instruction Administration/Instruction Record Resident: Ms. MA (list resident s full name) Month/Year: January 2011 Physician: Allergies: list resident s healthcare practitioner Codeine, ulfa drugs, dairy products Multi Vit 1 tablet 7 am every morning CBG aily Before Breakfast CBG aily Before inner 7am Results pm Results Reg Insulin 16 units Q 7 am before breakfast NPH Insulin H H 10 units Q o o 5 pm before dinner. l l Hold if CBG < 90 d d L-thyroxine 125 mcg every Mon, 7 am Tue, Thu, Fri & at H H o o l l d d Order discontinued see new order below Proventil 90 mcg Inhaler 2 puffs thru 1 pm mouth every 6 hours while awake 7 pm Tylenol 325 mg 2 tablets every 4 hours as needed for headache Milk of Magnesia 2 tablespoons Ms. M.A. (list the resident s full name) Resident: every day if no Month/Year: January 2011 BM for 3 days until ate has a BM Hour 01/07/11 Proventil 90 mcg spray L-thyroxine pm mcg every am started 1/17/ /15/11 1 pmnew order Proventil 90 mcg spray Instructions Physician: list resident s healthcare practitioner Allergies: Codeine, ulfa drugs, airy products Reason Results Hour Refused stated didn t need it No with breathing difficulty Out shopping No difficulty with breathing ignature A. Write initials in appropriate box at the 1 Best Caregiver time medication is given. B. Circle initials when medication is 2 IX Ifnx~Xm nky refused. C. tate reason for refusal in the narrative. 3. tate reasons PRN is given, and the Hour results. E. ate and initial all changes A Page 3 of 4 (01/05) Ensuring Quality Care 7 am 14 Medical Orders and Administration Record (MAR)

16 Medical visit report When a resident has a medical appointment with her or his primary health care practitioner and/or specialist, take a medical visit report that lists all the key information regarding any medications (including over-the-counter) the resident takes and if there are any concerns or issues with the medication. Example: Medical visit report 15 Medical Orders and Administration Record (MAR)

17 Oregon epartment of Human ervices This document can be provided upon request in an alternate format for individuals with disabilities. To request this publication in another format, contact the Publications and esign ection at , 711 for TTY, or