After the medication has been given, a record of the provision of medication must be made. Each resident will have a medication administration record (MAR) or sheet to write the name of the drug, dose, route, time, date and the medication aide’s signature, initials or both. Document in the resident’s MAR any actions or side effects of the drug that are observed. In addition, for a PRN medication, record why it was given and if it was effective (see additional activities). The chart is a legal record and cannot be altered. Care must be taken to make sure all documentation is legible and accurate.
If an error is made in providing medications, follow the facility policy to report the error. Usually this will mean reporting the error to the supervisor and/or the person doing the direction and monitoring. Also complete the appropriate form for recording medication errors following the employer’s policy.
Follow these guidelines for charting in a resident’s record:
- Each entry must be accurate and complete.
- Record only what is observed, not an interpretation of what is observed.
- Do not use unnecessary words or slang.
- Do not erase or cover errors. Make one line through the error and write “error” with your initials above the word “error,” or follow the facility policy.
- Record how a resident feels by writing his or her comments in quotations.
- Use only the abbreviations and ink color approved by the employer.
- Include symptoms reported by the resident, signs observed, care provided, and resident or family behavior.
- Avoid using empty phrases such as “Had a good day” or “Condition unchanged.”
- End each entry with the first initial, last name and title such as MA for medication aide.
- Never document a medication as being given before the medication is actually provided. It is very easy to get sidetracked and for the medication to be forgotten if it was documented prior to provision.
Accurate and complete documentation of medication provision is important for safe medication administration. Facility policies will differ for documentation. Some general guidelines for documentation include:
1. Clearly document the time and the date the medication was given;
2. Initial the time for every medication;
3. Write legibly;
4. Use only standard abbreviations approved by the facility;
5. Identify your initials with a full signature and title;
6. Document the medication only after the drug was provided to the resident; and
7. If the drug was not given, document the reason why.