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MAR - MEDICATION ADMINISTRATION RECORD
MAK UNITS ONLY Created 10/04
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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
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LEGEND AND SYMBOLS NOT ADMIN - * followed by Time, Initials
Example *2100BUSER ADMIN – Time followed by Initials Example BUSER NOT CHARTED - Time only Example 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
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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
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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
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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
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OTHER INFORMATION PATIENT INFORMATION NURSING ELECTRONIC SIGNATURES
Patient Identifiers Allergies NURSING ELECTRONIC SIGNATURES
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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
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EXAMPLES MAR HEADERS, SECTIONS AND ORDER DETAILS
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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
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ORDER DETAILS OVERVIEW
Brand/Generic Name Dosage, Strength, Route and Frequency Charting Information Start/Stop Date and Time Order Divider
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Routine (Scheduled) Orders
ROUTINE ORDERS Chart Date Order Information Routine (Scheduled) Orders Charting Information
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STOPPED/DISCONTINUED ORDERS
Section Header Based on Order Status Stop Date/Time Stop date occurred in MAR date range
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STOPPED DISCONTINUED ONE TIME ORDERS
Stopped or Expired One Time Orders Start Stop Date are Equal
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No Charted Occurrences
PRN ORDERS Order Section Header Active Order No Charted Occurrences
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PRN STOPPED/DISCONTINUED
Order Section Header Order Start/Stop Date Not Charted During MAR Date Range
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Start Date in Future at Print Time
FUTURE ORDER NOTATION Start Date in Future at Print Time
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REVIEW – MEDICATION MAR
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REVIEW - IV MAR
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EXAMPLES LEGENDS AND SYMBOLS
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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
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M = CHARTING DATA COLLECTION
Vital Sign, Blood Sugar or Pain Scale Information
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FREE TEXT DOSAGE AND SITE
Free Text Dose Entered (D=) Administration Site Vital or Blood Sugar (BS) and or Pain Scale (PS)
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CHARTING REASON/EFFECT AND HISTORY
EXAMPLES CHARTING REASON/EFFECT AND HISTORY
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CHARTING REASON AND EFFECT
Section Header Med, Occurrence Date/Time, Chart Time, User ID NOT ADMIN Reason PRN Reason
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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
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MAR REVIEW IMAGE file contains MAR document images
MAR REVIEW IMAGE file contains MAR document images. Please review this file. THANK YOU!
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