How Are Medication Administration Records Used in Different Healthcare Settings?

A primary aspect of effective patient care is managing the medication they receive. Without drug administration records or updates to a medical treatment plan, errors could occur. This puts the patient at risk of receiving too much or too little of a medication or the wrong medication. Medication administration records mitigate this risk.

The Medication Administration Records (MARs) detail drugs administered to patients during a specific treatment period or at a particular facility. Medical professionals must clearly note any medication they've given to the patient and any the patient self-administers. Even Tylenol (acetaminophen) must be recorded on the MAR, as it can cause drug interactions if administered and not known.

Different healthcare settings may use slightly different formats for MARs and follow varying processes. However, they should all feed back into a patient's medical record to help provide the highest quality of patient care.

MAR in Hospital Settings

Logging administered medication in a hospital setting is critical. Many staff members may visit a single patient, especially when that individual is hospitalized for an extended period. Without a clear MAR or drug chart, overdose is a serious risk.  

Patients may be in pain or suffering from other symptoms prompting them to ask for medication. If a nurse or doctor assesses the patient and decides to provide medication, this could make the patient seriously ill if they have already received the same medication recently. After all, patients are often unaware of when they last received a dose or how many hours must elapse before the next dose. Patients trust their hospital team to manage that.

Because of this, the patient's MAR will often be clipped to the foot of the patient's bed or hung inside their hospital room. Medication details may frequently be combined with other relevant care information, such as temperature, blood pressure, and other vital signs. Periodically, this data is summarized and added to the patient's healthcare record, making it available to the patient's other providers for future reference.

MAR in Care Homes

There are over 1.1 million residents of care homes in the United States, many of whom are elderly and/or vulnerable. Administering medication correctly is essential to ensure a high quality of life and optimal outcomes for these residents, particularly as many may require regular medication. However, these care homes present the added challenge of potentially multiple providers caring for a single patient. This is especially tricky when a patient initially transitions to a care home or nursing facility. All the patient's records must be combined to understand the patient's needs and build a comprehensive treatment plan.

In addition to clear MARs for every patient, care homes should also have a strict medication management policy with processes for every possible eventuality. Because nursing homes aren't hospitals, care is not solely focused on medical needs. Staff members here also provide social and other forms of care to help residents maintain their sense of dignity and reduce feelings of isolation. 

However, team members responsible for medical care must ensure that:

• Medication is given at the correct time.

• Residents don't share medications when unsupervised.

• Doses are never missed, even if the facility is understaffed.

• Multiple medications don't interact negatively.

• Allergies are noted and responded to swiftly in the event of any allergic reactions.

Any deviations from a patient's treatment plan must be documented on the MAR and reported to the care team, other medical staff, and necessary authorities as warranted.

Medication Administration Records for Ambulatory Healthcare Providers

Outpatient care is a vital aspect of many treatment plans. Once a patient is discharged from inpatient care, they may still require treatment at home. Some patients may never require hospitalization and may rely entirely on ambulatory healthcare.

MARs for this type of treatment are usually found as part of the ambulatory medical records (AMR). These records typically don't include highly detailed inpatient data such as clinical reports or lab results. However, they should consist of any medication the patient is currently taking, recent changes to medication or dosing levels/intervals, and relevant recommendations from attending personnel. Importantly, if a medical professional decides to administer drugs to the patient during a visit, this must be logged immediately. 

There should also be processes in place to ensure the patient's health record gets updated as quickly as possible. If a patient is hospitalized in the near future, the receiving medical team can quickly view the medications most likely to be in their system. Physicians can then administer other medications safely without concern for potential interactions.

The Impact of Electronic Medication Administration Records

Switching from paper-based to electronic medication administration records (eMARs) has several benefits that all types of healthcare settings should consider. As mentioned, instantly updating a patient's healthcare record is crucial for patient safety and improved outcomes. However, with paper-based records, this would have to be done over the phone or by emailing another facility with the relevant details. This can take time and may prevent the patient from receiving the care they need promptly.

Electronic health records (EHRs) should have the ability to receive medical information from multiple providers digitally. For example, a mobile physical therapist who administers painkillers should be able to: 

1. Instantly access the patient's recent MAR summary to see any potential interactions.

2. Update the EHR digitally using an online platform.

Using eMARs helps medical professionals understand a patient's healthcare and medication history and develop the most beneficial treatment plan.

The Right Support for Electronic Health Records

TempDev's team of NextGen consultants, developers, and trainers supports your needs whether you're looking to implement, switch, or upgrade your current EHR system. A more effective EHR solution could help your facility manage electronic medication administration records (eMARs) more effectively. From dashboards and revenue cycle consulting to workflow redesign and automation, TempDev offers tools and expert advice to help you optimize your NextGen EHR system. 

Contact us online or call us at 888.TEMP.DEV to learn more about how we can help you with all aspects of patient records.