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MAR - MEDICATION ADMINISTRATION RECORD

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

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

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. OTHER INFORMATION • PATIENT INFORMATION • Patient Identifiers • Allergies • NURSING ELECTRONIC SIGNATURES

  8. 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

  9. EXAMPLES MAR HEADERS, SECTIONS AND ORDER DETAILS

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

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

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

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

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

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

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

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

  18. REVIEW – MEDICATION MAR

  19. REVIEW - IV MAR

  20. EXAMPLES LEGENDS AND SYMBOLS

  21. 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

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

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

  24. EXAMPLES CHARTING REASON/EFFECT AND HISTORY

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

  26. 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

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

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