MAR - MEDICATION ADMINISTRATION RECORD MAK UNITS ONLY Created 10/04

KEY COMPONENTS HEADERS/SECTIONS: MAR ORDER DETAILS: PAGE HEADER Type of MAR (i.e. Medication or IV) MAR Date Range Displays up to 5 Days of Med Summary ORDER SECTIONS ROUTINE ORDERS Scheduled Orders (i.e. QAM) PRN ORDERS STOPPED/DC’D STOPPED/DC’D ROUTINE Expired/Discontinued Scheduled Orders STOPPED/DC’D PREOP/STAT/URGENT One Time Order STOPPED/DC’D PRN Expired/Discontinued PRN Orders MAR ORDER DETAILS: BRAND/GENERIC NAME IV DESCRIPTION DOSAGE STRENGTH ROUTE FREQUENCY (i.e. BID) ORDER START / STOP DATE ****FUTURE ORDER*** START DATE IN FUTURE AT PRINT TIME ****DISCONTINUED ORDER*** STOP DATE OCCURRED IN MAR DATE RANGE ****NO ADMINISTRATIONS*** PRN MEDS NOT CHARTED IN MAR DATE RANGE

LEGEND AND SYMBOLS NOT ADMIN - * followed by Time, Initials Example *2100BUSER ADMIN – Time followed by Initials Example 2100BUSER NOT CHARTED - Time only Example 2100 HIST – Charted Occurrence has been revised M= Charted Vitals or Pain Scale values T = Temp R = Respiration HR = Heart Rate PS = Pain Scale BS = Blood Sugar Blood Pressure noted by value/value

LEGEND AND SYMBOLS – cont’d D= Free Text Charted Dose Site – Site of Administration T = Temp R = Respiration HR = Heart Rate PS = Pain Scale BS = Blood Sugar Blood Pressure noted by value/value

CHARTING REASON AND EFFECT SECTION Supplemental Section of MAR Provides additional charting data Reason Documented reason med administered or not administered Effect Documented effectiveness for administered med

CHARTING HISTORY SECTION Supplemental Section of MAR Provides charted data revision information Details old and new charted data information Occurrence Status Administered to Not Administered Not Administered to Administered Date and Time Reason and Effectiveness Administered Dose Administration Site Vital Sign, Pain Scale or Blood Sugar collected data Revisions cannot be made to the original chart or cosign user identification

OTHER INFORMATION PATIENT INFORMATION NURSING ELECTRONIC SIGNATURES Patient Identifiers Allergies NURSING ELECTRONIC SIGNATURES

MAR IMPORTANT FACTS PATIENTS ON MAK UNITS Permanent Chart Copy MAR for MAK Unit discharged patients will be printed directly to Medical Records at dayend Unit MAR printed directly to unit each day Normal print time - 10 PM Used as a reference MAR

EXAMPLES MAR HEADERS, SECTIONS AND ORDER DETAILS

Section Header Based on Order Status LAYOUT OVERVIEW MAR Date Range MED or IV MAR Header Charting Date Section Divider Order Details Section Header Based on Order Status

ORDER DETAILS OVERVIEW Brand/Generic Name Dosage, Strength, Route and Frequency Charting Information Start/Stop Date and Time Order Divider

Routine (Scheduled) Orders ROUTINE ORDERS Chart Date Order Information Routine (Scheduled) Orders Charting Information

STOPPED/DISCONTINUED ORDERS Section Header Based on Order Status Stop Date/Time Stop date occurred in MAR date range

STOPPED DISCONTINUED ONE TIME ORDERS Stopped or Expired One Time Orders Start Stop Date are Equal

No Charted Occurrences PRN ORDERS Order Section Header Active Order No Charted Occurrences

PRN STOPPED/DISCONTINUED Order Section Header Order Start/Stop Date Not Charted During MAR Date Range

Start Date in Future at Print Time FUTURE ORDER NOTATION Start Date in Future at Print Time

REVIEW – MEDICATION MAR

REVIEW - IV MAR

EXAMPLES LEGENDS AND SYMBOLS

CHARTING STATUS REVIEW Order Section Header ADMIN – Time and User ID NOT ADMIN – asterisk (*) f/b Time and User ID NOT CHARTED – Time w/o any other information HIST – Revision Details for Charted Occurrence

M = CHARTING DATA COLLECTION Vital Sign, Blood Sugar or Pain Scale Information

FREE TEXT DOSAGE AND SITE Free Text Dose Entered (D=) Administration Site Vital or Blood Sugar (BS) and or Pain Scale (PS)

CHARTING REASON/EFFECT AND HISTORY EXAMPLES CHARTING REASON/EFFECT AND HISTORY

CHARTING REASON AND EFFECT Section Header Med, Occurrence Date/Time, Chart Time, User ID NOT ADMIN Reason PRN Reason

Post – Revise, New Charted Date/Time and Revised Entry Value CHARTING HISTORY Order, Occurrence Date/Time, Charted Date/Time and Revised Data Element _ OLD Section Header Post – Revise, New Charted Date/Time and Revised Entry Value

MAR REVIEW IMAGE file contains MAR document images MAR REVIEW IMAGE file contains MAR document images. Please review this file. THANK YOU!