filling out medication administration records - DPHHS

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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 practitioners and other workers, and providing documentation as to the course of illness, treatment, and response to this treatment. They serve as a basis for review, study, and evaluation of the health care given. The medical record is confidential and should not be shown or discussed with anyone not administering care to the individual. All accounts of the person’s condition and care are written and signed by the person giving the care or entered into the computer record. These accounts should reflect observed facts, not opinions or judgments. As mentioned above, the Medication Administration Record (MAR) is used to document medications taken by each individual. The MAR includes 

a column which lists the names of the medications that are prescribed.



a start date for each prescribed medication is sometimes noted and a stop date when known.



the times and dates the medication is to be taken

 the initials of the person assisting with the medication. The listed medications are from the medical practitioner’s orders and the process by which they appear there is known as “transcribing”. Transcribing involves copying the prescriber’s orders onto the Medication Administration Record (MAR). MAR’s are sometimes provided by the pharmacy. However, sometimes a new medication is prescribed late in the day or on weekends from the hospital pharmacy and a pharmacy generated MAR is not available. In that case, you will need to transcribe that order to the MAR so that others are aware of the new medication or change in dosing. This in turn, ensures that the medication is taken as ordered.

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 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(s). 3. Your initials and signature must be in an appropriate space on each MAR. 4. Ditto marks are never used. January 13, 2016 JJustad, MD, DDP

FILLING OUT MEDICATION ADMINISTRATION RECORDS 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 it. 6. Record onto the MAR immediately after you see that the medication was swallowed 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 with 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.

1. FILLING OUT THE MEDICATION ADMINISTRATION RECORD Filling out the MAR may appear difficult but it is actually quite simple. Simply write down the information from the prescription in an organized fashion so that you do not make mistakes or forget to record anything. Transcription errors are common and can be fatal. You must pay close attention to what the prescription states and how you transcribe it onto the MAR. If you are unsure of the directions or anything else on a prescription, ask the prescriber to clarify. You may work for a provider that obtains a MAR that is already set up by the pharmacy. This is fine to use but it is still very important to understand how to fill out a MAR so that you better understand how to interpret the information it contains. Plus, there may be a time that you are asked to add a medication to the MAR or change how a medication is being given based on a written order from a prescriber. If you understand the MAR fully, you will also be able to see any errors that may have occurred by someone else filling it out. If the MAR comes from the pharmacy, that does not mean that errors cannot occur. You should always have copies of prescriptions or at the very least, a notation from the prescriber as to what has been prescribed and how the medication is to be given. This should be checked against the MAR when the medication is received and prior to the medication being taken for the first time. Errors occur; you should be able to prevent them if you pay attention to both the prescription and to the MAR. Following are examples of prescriptions and the Medication Administration Record (MAR) that would be filled out based on that prescription. The MAR forms used in this book have larger squares for information than most MARs that you will see. This is for ease of learning. Because of the larger squares, it will only show a partial month. When you take your certification test, you will be given information and a prescription as seen in the examples shown. You must be able to read through the information presented, understand the prescription and by using that prescription, fill out the MAR correctly on your test. 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. January 13, 2016 JJustad, MD, DDP

FILLING OUT MEDICATION ADMINISTRATION RECORDS Example # 1 You have taken Joe Smith to see Dr. Davis because of his runny nose and cough. Dr. Davis diagnoses 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 has allergies to Penicillin and to oranges.

Davis and Hartman Medical Group, PLLC 1011 Jackson Helena, MT 59604 406-442-6779 Name: Joe

Smith

Date:

January 3. 2015

DOB: ____11/16/58______________

Rx: Allegra 60 mg Sig: one tab po bid Refill x 1 year

#60

Zithromax 250 mg #6 Sig: give two tabs po today, then one tab po qd until gone Signed:

Ron Davis, MD Ron Davis, MD

January 13, 2016 JJustad, MD, DDP

FILLING OUT MEDICATION ADMINISTRATION RECORDS Before writing on the MAR, let’s look at the prescription. Above is an example of the way that prescriptions 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 name of the person 2. The date the prescription was written 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 prescription will not signify “po” as the route for taking the medication. Unless some other route is given, assume that the medication is given by mouth and write that on the MAR. d. The number of pills or amount of medication prescribed e. Refills (if applicable) 5. The signature and name of the physician You should 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). You will also need to have an understanding for the times during the day that medications are routinely given. If a prescription states to give something BID, you need to know that it means that medication is given twice a day and also what time of day it is given. You must also know that BID is different from 2 qd which means two daily. When something is written 2 qd or 3 qd, etc. it means that number of pills is given once a day together. When something is written to be given two, three, or four times a day; it generally means that it is given at intervals during normal awake hours. Instead of waking someone up during the night to give a QID medication (4 times a day) it would generally be given at approximately equal intervals throughout the normal waking hours between 6 or 7 am and 8 or 9 pm. If a medication needs to be given at more exact intervals during the entire day, it will be written as “q 6 hrs” which means the medication is taken every 6 hours throughout the 24 hour day. Following are some dosing schedules that you will see and ones that you should use on the test. The most frequently used dosing times for BID, TID, and QID medications. AM

DAYTIME

BID

6, 7, 8

TID

6, 7

12, 1

QID

6, 7

11, 12

January 13, 2016 JJustad, MD, DDP

PM 6, 7, 8 7, 8

3, 4

8

FILLING OUT MEDICATION ADMINISTRATION RECORDS 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 -or7 am, 1 pm, 7 pm, 1 am

q 8 hrs -or- every 8 hours

6 am, 2 pm, 10 pm -or7 am, 3 pm, 11 pm

The most frequently used schedules for intermittent medication dosing during a week. 2 x per WEEK -or-

Monday & Thursday -or-

TWICE WEEKLY

Tuesday & Friday -orWednesday & Saturday or Sunday

3 x per WEEK -or-

Monday, Wednesday, Friday (MWF) -or-

3 TIMES WEEKLY

Tuesday, Thursday, & Saturday or Sunday

4 x per WEEK -or4 TIMES WEEKLY

Saturday, Sunday, Tuesday, Thursday (SSTTh)

With the information that you have been given, you will start to fill out the MAR. This is done in a stepwise manner. For these instructions, you will be shown each change on the MAR as you go through each step. 1. Note the name on the prescription and make sure it either matches that given on the MAR that you are going to fill out or fill it in yourself. In this case, Joe Smith and his birthdate are filled in at the bottom of the page. (This will be shown once the entire MAR is completed.) 2. The prescriber’s name should also appear at the bottom of the MAR. 3. The first medication listed is Allegra with the dose of 60 mg – write this under the column for “medication” at the far left. Medication Allegra 60 mg

JAN start

HR

1

2

3

4

5

6

7

8

9

10

11

12

4. The instructions (or “sig”) are “one tab po bid” – this means: one tablet by mouth twice daily. Those are the instructions that should be written below the medication name and dose in the first column. Medication Allegra 60 mg one tablet by mouth twice daily

JAN Start

HR

January 13, 2016 JJustad, MD, DDP

1

2

3

4

5

6

7

8

9

10

11

12

FILLING OUT MEDICATION ADMINISTRATION RECORDS 5. 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 3rd 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 Medication Allegra 60 mg one tablet by mouth twice daily

JAN start

HR

1

2

3

4

5

6

7

8

9

10

11

12

1/3/15

6. Next fill in the “HR” or hour that the medication is to be taken. In the group home where Joe lives, medications are usually given at 7 am and 7 pm. You write those times under the “HR” heading on two separate lines. Medication Allegra 60 mg one tablet by mouth twice daily

JAN start 1/3/15

HR

1

2

3

4

5

6

7

8

9

10

11

12

7am 7pm

7. The last item is to fill in the areas that need to be blocked off under each date. The medication is started on the night of January 3rd; therefore each day prior to that date must be “X’d” off to show that the medication was not given on those days. The medication will continue indefinitely (thus no known “stop” date), therefore the squares after January 3rd would be left open so that anyone assisting with medications can place initials in the appropriate square. If you were to assist with the medication that evening, your initials would appear in the box under “3” and across from “7pm”. This is designated as “IN” below. Medication Allegra 60 mg one tablet by mouth twice daily

JAN start 1/3/15

HR

1

2

3

7am

X

X

X

7pm

X

X

IN

4

5

6

7

8

9

10

11

12

8. Now we move to the next medication on the prescription: Zithromax. This medication has two different instructions for use that you must transcribe onto the MAR. Whenever there are two different instructions for one medication, you must write the medication name twice on the MAR in two separate boxes on the left. January 13, 2016 JJustad, MD, DDP

FILLING OUT MEDICATION ADMINISTRATION RECORDS Medication Zithromax 250 mg

JAN

HR

1

2

3

4

5

6

7

8

9

10

11

12

Zithromax 250 mg

9. 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 Zithromax 250 mg 2 tablets by mouth today

JAN

HR

1

2

3

4

5

6

7

8

9

10

11

12

Zithromax 250 mg 1 tablet by mouth daily until gone

10. 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 daily until gone” which means that you would give the second dose (one tablet) starting on January 4th. Medication Zithromax 250 mg 2 tablets by mouth today

JAN

Zithromax 250 mg 1 tablet by mouth daily until gone

start

HR

start 1/3/15

1/4/15

January 13, 2016 JJustad, MD, DDP

1

2

3

4

5

6

7

8

9

10

11

12

FILLING OUT MEDICATION ADMINISTRATION RECORDS 11. Next fill in the “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 taken every morning so 7 am is an appropriate time. Medication Zithromax 250 mg 2 tablets by mouth today

JAN start

HR

1/3/15

3pm

Zithromax 250 mg 1 tablet by mouth daily until gone

start 1/4/15 7am

1

2

3

4

5

6

7

8

9

10

11

12

12. Next block out the days the medication is not to be taken. a. Zithromax, 2 tablets is taken only on January 3rd so all boxes up to and after January 3rd are crossed out. 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 a total of 4 days starting on January 4 th. All boxes before January 4th and after January 7th are crossed out. c. Since this medication is given for a short time you can also put in a stop date if desired. Medication Zithromax 250 mg 2 tablets by mouth today

JAN start 1/3/15

Zithromax 250 mg 1 tablet by mouth daily until gone

start 1/4/15

HR

1

2

3pm

X

X

7am

X

X

stop 1/7/15

January 13, 2016 JJustad, MD, DDP

3

4 X

X

5

6

7

X

X

X

8 X

X

9

10

11

12

X

X

X

X

X

X

X

X

FILLING OUT MEDICATION ADMINISTRATION RECORDS Another possible way to fill out the MAR such as this one when Zithromax is given for only 4 more days would be to number (1 through 4) beneath the open boxes. This can act as a double check when giving a medication for a limited number of days. Medication Zithromax 250 mg 2 tablets by mouth today

JAN start 1/3/15

Zithromax 250 mg 1 tablet by mouth daily until gone

start 1/4/15

HR

1

2

3pm

X

X

7am

X

3

4

5

X

X

6

X

7 X

8 X

X

X

X 1

Stop 1/7/15

2

3

9

10

11

12

X

X

X

X

X

X

X

X

4

Below is the complete MAR for the two medications prescribed on January 3 rd. Medication Administration Record Medication Allegra 60 mg one tablet by mouth twice daily Zithromax 250 mg 2 tablets by mouth today

Zithromax 250 mg one tablet by mouth daily until gone Diagnosis:

JAN

HR

1

2

3

7am

X

X

7pm

X

X

4

5

6

7

8

9

10

11

12

start 1/3/15

X

xx

start 1/3/15

3pm

X

X

7am

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

start 1/4/15

X

allergic rhinitis, bronchitis

Allergies: Penicillin, oranges Name: Physician: Joe Smith Dr Ron Davis Date of Birth: Phone number: 11/16/58 442-6779

January 13, 2016 JJustad, MD, DDP

IN NR cp

Name Nan Roberts Caroline Peters

IN TJ

Name Tim Jones

FILLING OUT MEDICATION ADMINISTRATION RECORDS Example # 2: Carol is having problems with constipation so when she sees Dr. Davis Monday afternoon for a regular follow up, you inform him of this problem. He writes a prescription that will help her with this. After you pick up the prescription, you fill out the MAR using the information provided after 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 Name: Carol DOB:

Potter

Date:

March 2, 2015

4/10/1985

Rx: Miralax 17 gm mixed with 8 oz. fluid Disp: one month supply Sig: drink q am twice weekly 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 that needs to be clear on the MAR also. Medication

March

Miralax 17 grams mixed with 8 ounces of fluid

start

HR

1

2

3

4

5

6

7

8

9

10

11

12

2. It states to “drink” which translates into taking orally or by mouth so write that on the MAR. 3. Add how often it is to be taken: a. q am or “every” which indicates that it is taken “in the morning” so you could use 7 am b. twice weekly or twice a week Medication

March

HR

Miralax 17 grams mixed with 8 ounces of fluid by mouth every morning twice a week

start

7am

January 13, 2016 JJustad, MD, DDP

1

2

3

4

5

6

7

8

9

10

11

12

FILLING OUT MEDICATION ADMINISTRATION RECORDS 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, Tuesday. c. It is to be taken twice a week so if it starts on Tuesday, taking it on Tuesday and Friday would be correct. d. From the prescription which was written on March 2nd (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 as it is simply a reminder of the day of the week). Medication

March

HR

1

Miralax 17 grams mixed with 8 ounces of fluid by mouth every morning twice a week

start

7am

X

2 M X

3 T

4 W X

5 Th X

6 F

7 S X

8 S X

9 M X

10 T

11 W X

12 Th X

3/3/15

After filling in the diagnosis and the allergies, the completed MAR would appear as below. Medication administration record (MAR) Medication

March

HR

Miralax start 17 grams 3/3/15 mixed with 8 ounces of fluid by mouth every morning twice a week Diagnosis: Constipation

7am

Allergies: none Name: Carol Potter Date of Birth: 4/10/1985

Physician: Dr Ron Davis Phone number: 442-6779

January 13, 2016 JJustad, MD, DDP

1

2 X

3 X

4

5 X

6 X

7

8

9

X

X

X

10

IN

Name

IN

Name

NR

Nan Roberts

TJ

Tim Jones

cp

Caroline Peters

11

12

X

X

FILLING OUT MEDICATION ADMINISTRATION RECORDS Example # 3: You just took Brian to see Dr. Davis for follow up. Brian’s protime results 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 6th is a Wednesday. Brian has allergies to shellfish and Penicillin. Davis and Hartman Medical Group, PLLC 1011 Jackson Helena, MT 59604 406-442-6779 Name: Brian

Hunter

Date:

DOB: 1/3/40

February 5, 2015

.

Rx: Warfarin 1 mg # one month supply Sig: take 2 tablets po q M,W,F and 3 tablets po q S,S,T,Th for atrial fibrillation starting tomorrow Signed:

Ron Davis, MD Ron Davis, MD

Just as in the first example, there is one medication but two doses to consider. Each dose must go on a separate line on the MAR. 1. The warfarin is currently being taken by Brian at 3 mg daily (or three 1 mg tablets daily) and the days that he has taken it are already marked off with initials as you can see below. Since the new dose of warfarin starts tomorrow which would be February 6th, the current dose is taken through the 5th, therefore those boxes are left open to initial when that dose is swallowed. With the new dose starting on February 6th, all boxes after the 5th should be crossed out to signify that the “3 tablets daily” dose has changed. You can also write in the stop date of February 5th. The stop date is the date that the last dose was taken. Medication

FEB

Warfarin 1mg 3 tablets by mouth daily

start 8/4/07 Stop 2/5/15

January 13, 2016 JJustad, MD, DDP

HR

2 pm

1

2

3

NR

NR NR

4

NR

5

6

X

7

8

X

X

9

10

11

12

X

X

X

X

FILLING OUT MEDICATION ADMINISTRATION RECORDS 2. Next you look at the new instructions for giving warfarin. 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 5th with instructions to start the new dosing schedule “tomorrow” which would be February 6 th. You were also told that the 6th is a Wednesday therefore you know that the two 1 mg tablets start on the 6th and would also be taken on the 8th, and 11th. 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. The medication was already being taken at 2 pm so you would continue with that hour. Medication Warfarin 1 mg 2 tablets by mouth on Monday, Wednesday, and Friday

FEB

HR

1

2

3

4

5

start 2/6/15

2 pm

X

X

X

X

X

6

7

8 X

9

10

X

X

11

12 X

3. To make it easier to fill out and read the MAR when a medication is given on specific days of the week, write the day of the week beneath the date. These notations can be abbreviated. Medication Warfarin 1 mg 2 tablets by mouth on Monday, Wednesday, and Friday

FEB start 2/6/15

HR 2 pm

1

2 X

X

3 X

4 X

5 X

6

7

8

9

10

11

12

W

TH

F

S

S

M

T

X

X

X

X

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, ie. February 1 through 6 would be X’d out. Also Friday and Monday (the 8th and 11th) would be X’d out as those are the days that 2 tablets are taken. Medication Warfarin 1mg 3 tablets by mouth on Saturday, Sunday, Tuesday, and Thursday

FEB start 2/7/15

January 13, 2016 JJustad, MD, DDP

HR 2 pm

1 X

2 X

3 X

4 X

5 X

6

7

8

9

10

11

12

W

TH

F

S

S

M

T

X

X

X

FILLING OUT MEDICATION ADMINISTRATION RECORDS 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 administration record (MAR) Medication Warfarin 1 mg 3 tablets by mouth daily

FEB start

HR

8/4/07

2 pm

1

2

3

4

5

NR NR NR NR

6

7

8

9

10

11

12

X

X

X

X

X

X

X

X

X

Stop 2/5/15 Warfarin 1mg 2 tablets by mouth on Monday, Wednesday and Friday Warfarin 1 mg 3 tabs by mouth on Saturday, Sunday, Tuesday, and Thursday Diagnosis:

start

2 pm

X

X

X

X

X

2 pm

X

X

XX

X

X

X

X

2/6/15

start

X

X

X

2/7/15

atrial fibrillation

Allergies: shellfish, penicillin

IN

Name

IN

Name

Name: Brian Hunter Date of Birth: 1/3/40

NR

Nan Roberts

TJ

Tim Jones

cp

Caroline Peters

Physician: Dr Ron Davis Phone number: 442-6779

January 13, 2016 JJustad, MD, DDP

FILLING OUT MEDICATION ADMINISTRATION RECORDS 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 and after comparing it to your copy of the prescription to make sure that you have received the correct medication and that the directions match, you then write out the MAR. Caleb is allergic to Tegretol and Penicillin. Davis and Hartman Medical Group, PLLC 1011 Jackson Helena, MT 59604 406-442-6779 Name: Caleb

Harris

February 1, 2015

Date:

DOB: 4/10/82

.

Rx: Depakote 500 mg # 1 month Sig: one tab po q am x 1 wk, then bid Refill x 1 year 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 Depakote 500 mg

FEB start

Depakote 500 mg

start

HR

1

2

3

4

5

6

7

8

9

10

Diagnosis: Allergies: Name: Caleb Harris Date of Birth: 4/10/82

Physician: Dr Ron Davis Phone number: 442-6779

January 13, 2016 JJustad, MD, DDP

IN

Name

IN

Name

NR

Nan Roberts

TJ

Tim Jones

cp

Caroline Peters

11

12

FILLING OUT MEDICATION ADMINISTRATION RECORDS 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. Medication

FEB

Depakote 500 mg One tablet by mouth daily for one week, then

start

Depakote 500 mg One tablet by mouth twice daily

start

HR

1

2

3

4

5

6

7

8

9

10

11

12

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 2nd as the appointment was on the afternoon of February 1st. b. The twice daily dosing starts one week (7 days) later so the starting date would be February 9th. 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 7am and 8pm. Medication

FEB

HR

Depakote 500 mg One tablet by mouth daily for one week, then

start

7am

Depakote 500 mg One tablet by mouth twice daily

start

1

2

3

4

5

6

7

8

9

10

11

12

2/2/15

7am

2/9/15 8pm

4. Now X out the days prior to the start date for each dosing schedule and also X out the days following the one week of the medication being prescribed in the morning only. You can also put in a stop date for the once daily dose. 5. Be sure to fill in allergies and diagnosis.

January 13, 2016 JJustad, MD, DDP

FILLING OUT MEDICATION ADMINISTRATION RECORDS Medication

FEB

HR

1

2

3

4

5

6

7

8

Depakote 500 mg One tablet by mouth daily for one week, then

start

7am

X

7am

X

X

X

X

X

X

X

X

8pm

X

X

X

X

X

X

X

X

9

10

11

12

X

X

X

X

2/2/15 stop 2/8/15

Depakote 500 mg One tablet by mouth twice daily

start 2/9/15

Diagnosis: Seizures Allergies: Tegretol, Penicillin

IN

Name

IN

Name

Name: Caleb Harris Date of Birth: 4/10/82

NR

Nan Roberts

TJ

Tim Jones

cp

Caroline Peters

Physician: Dr Ron Davis Phone number: 442-6779

These 4 examples should prepare you for filling out almost anything on a MAR. You should do the practice examples following this chapter. You will be asked to fill in a MAR on your exam so practice will help you to be able to do this quickly and confidently.

January 13, 2016 JJustad, MD, DDP

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filling out medication administration records - DPHHS

FILLING OUT MEDICATION ADMINISTRATION RECORDS The ABC’s of charting include: A. Accurate B. Brief C. Completely objective A medical or health record i...

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