Record Keeping
Record Keeping
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On completion of this section you should have an understanding of:
What documents we use to record care
Medicines Administration Records (MAR)
How staff should create a new MARs
How a person’s needs and risks are assessed
What records do we use?
Laws and regulations say that organisations must keep records relating to the care and treatment of each person using the service
These records must be accurate, up to date, complete and detailed
Must include details of decisions in relation to care and treatment
Must include consent records
Organisations do this by developing a Care Plan which supports the person with their care and treatment and includes details about their medicines, and by using medicines administration records to record everything that is done concerning the administration of medicines.
Documentation for medication support
It is vital that all support given for medication is recorded accurately. This is usually done using a Medicines Administration Record (MAR).
The MAR chart should list all the person’s medication and the directions for giving the medication.
There are different types of MAR chart available, but they are designed to provide a clear way to record the support given for each medication for each person.
You may also have to complete other records about medication such as
Records to show how much medication has been received
Records to show how much medication has been disposed of
Records to show what medication has been ordered and when
Ask to see a MAR chart at your organisation
Remember your MAR charts may not look exactly the same as the sample MAR chart shown on the next page but it should have some space to record the following information. (click on the numbers below to reveal the information)
1
Spaces to record each medication
2
Space to clearly record the person’s name and date of birth (DOB) and any allergies
3
Space where you need to sign if you gave medication
Medicines Administration Record (MAR) Chart
Do:
Sign the MAR (or use the appropriate MAR code) after administration but before moving on to support the next service user or complete a new task.
Record the exact quantity administered for varied dose e.g. take one or two
Record the time of administration for paracetamol containing products
Do Not sign the MAR :
before administration
from memory e.g. at the end of the medicine 'round' or the end of your shift.
for medicines that you have not personally administered i.e. on behalf of another carer.
For more information please use the link to visit CQC Medicines information for adult social care services guide 'Medicines administration records in adult social care' - https://www.cqc.org.uk/guidance-providers/adult-social-care/medicines-information-adult-social-care-services
an example of completed MAR chart
Transcribing and patient safety
Any act by which medicinal products are written from one form of direction to administer to another is transcribing. This includes, for example, discharge letters, transfer letters, copying illegible patient administrations charts onto new charts,whether hand-written or computer generated.
- Nursing and Midwifery Council (NMC)
When does it happen?
Transcribing is sometimes necessary when there is no access to MAR. It allows the continuation of administration of medicines where the patient would be at risk if the medicines were withheld.
Care providers should make sure that new transcribed MARs (Also called handwritten MARs) are provided by all staff only in exceptional circumstances.
Who can transcribe?
Members of care staff with the training and skills for managing medicines. In care home settings and settings where there are two trained staff members working, the new record should be checked for accuracy and signed by a second trained and skilled member of staff before first used.
In social care settings where only one member of staff is present (i.e lone working) the trained and skilled staff member could transcribe the item(s) to the MAR chart, take a break and complete a different task, then recheck before administering medication or care provider should ensure a second check is arranged.
Transcribing
Always refer to your local policies and procedures
Information must be transcribed exactly as it appears on the pharmacy label (ideally transcribe from two up to date sources for example the pharmacy label plus, the GP repeat slip, copy of the original prescription, hospital discharge letter, etc)
Ensure MAR's are legible (readable), clear, accurate, avoid jargon and avoid abbreviations.
The full name, date of birth of the patient, the route of administration and allergy status must also appear on the MAR.
A start date must appear on the MAR chart making it clear when it was started.
Click on the headings below the pharmacy label, this demonstrates what information needs to be transcribed onto the MAR.
Always refer to your local policies and procedures
Cautionary Label
Cautionary Label
Drug Name
Drug Name
Directions
Directions
Patients Name
Patients Name
Quantity
Quantity
Form
Form
Assessing a person’s needs and risks
When medication support is required risk assessments are carried out to ensure the care given is safe.
✔️ A person’s knowledge of their health and medication-what do they know and understand?
✔️ Methods of communication and any specific communication needs
✔️ Number of medicines person takes, types of medicines - any time sensitive medicines
✔️ Persons physical condition-e.g. are they able to open medicines packs/see clearly/hear clearly/swallow easily/any episodes of confusion
✔️ If self-administering: are they able to manage or do they require a review from their community pharmacy to see what reasonable adjustments could be made to support them such as reminder charts, large print labels, winged lidded bottles, monitored dose system, a compliance aid, other equipment to help
✔️ How will storage of medicines be managed to keep medicines safe but without affecting persons access
✔️ Will anyone else be involved in their medicines care and administration of medicines
Section 2: Record Keeping
In this section we have looked at:
What documents we use to record care
Medicines Administration Records (MAR)
How staff should create a new MARs
How a person’s needs and risks are assessed
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