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MAR - MEDICATION ADMINISTRATION RECORD . MAK UNITS ONLY Created 10/04. HEADERS/SECTIONS: 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

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Mar medication administration record l.jpg

MAR - MEDICATION ADMINISTRATION RECORD

MAK UNITS ONLY

Created 10/04


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HEADERS/SECTIONS:

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

KEY COMPONENTS


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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


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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

    • 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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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 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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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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FUTURE ORDER NOTATION

Start Date in Future at Print Time




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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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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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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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