PCS

Class 4: MAR

MAR: Medication Administration Record

v  Overview Page 2

v  Screen Overview Page 2

Ø  Manually Discontinued Page 3

Ø  Automatic Discontinued Page 3

v  Selecting a Medication Page 4

v  Administering a Medication Page 4

Ø  Entering a Comment Page 5

Ø  Non-administration reasons Page 6

Ø  Adjusting a Dose Page 7

Ø  Changing the next scheduled time Page 7

v  Viewing Medication Information Page 8

Ø  View Dose instruction Page 9

Ø  Viewing/Entering/Editing Label Comments (MAR) Page 9

Ø  Viewing Drug monographs Page 10

Ø  Viewing Allergies Page 11

v  Viewing Additional Patient Information Page 11

Ø  Associated data Page 11

Ø  Personal information Page 12

v  Viewing MAR from the EMR Page 12

v  Cosignature for Medication Administration Page 12

MAR Edit

v  Overview Page 13

v  Screen and Menu options Page 13

v  Overview of Edit Page 14

v  Edit Assessment for Administration Page 14

v  Entering Comments Page 15

v  Administration Comments Page 15

v  Non-Administration Reasons Page 16

v  Adjusting the Dose Page 16

v  Viewing medication and patient Information Page 17

Retrospective MAR

v  Overview Page 17

v  Screen and Menu Options Page 18

v  Overview of Retro MAR Page 18

v  Administering a scheduled medication Page 18

v  Administering an unscheduled medication Page 19

v  Undoing changes Page 20

v  Entering Comments

Ø  Administration Comments Page 20

Ø  Non-Administration Reasons Page 20

v  Adjusting Dose Page 21

v  Viewing medication and patient Information Page 22

REPORTS Page 22

Medication Administration Record (MAR)

Overview

The Online MAR (Medication Administration Record) allows you to document activity related to medications. You can use this feature to do any of the following:

·  document the administration of a medication

·  enter a comment related to the administration of a medication

·  enter the reason a medication was not administered

·  adjust the actual dose that is being administered e.g. Tablets that are 1 or 2

·  view a medication's scheduled administrations

·  change a medication's schedule

·  view a medication's order

·  view a medication's dose instructions

·  enter, edit, or view a medication's label comments

·  view a medication's monograph

·  access Allergy Management

·  view associated data for a specific medication

·  access an individual's Enterprise Medical Record (EMR)

Notes: Note that when the cursor moves over an available menu option or medication name ("clickable" areas) on the MAR screen, the usual shape of the cursor is changed to a pointing hand. A check mark ( ) appears before a medication that has been administered but not yet filed.

Screen Overview

Colors on the MAR Screens

Colors in the columns of the medication list on the MAR screens convey information about the medication orders.

This color / In This Column / Indicates that the medication
Black on a blue Background / All columns (Except LAST GIVEN under certain conditions) / Is selected
Blue on gray background / Medication Column / Is NOT selected
Red / Last Given / Is overdue
Green / Last Given / Was administered in the current session but administration is not yet filed
Yellow
(does not appear on MAR edit screen) / All columns except Medication / Was discontinued

Manually Discontinued Medications

v  Medications manually discontinued (in Pharmacy) immediately appear with a yellow background on the MAR and Retro MAR screens.

v  If scheduled, unadministered doses exist for discontinued medications, the dose dates and times appear with a red background in the Last Given column in both MAR and Retro MAR.

v  In MAR, manually discontinued medications remain on the medications list for 24 hours after the yellow background and the DC notation appear. In Retro MAR, manually discontinued medications remain on the list for a period specified for your facility.

Automatically Discontinued Medications

v  Medications are automatically discontinued when they reach their stop dates.

v  In MAR, the yellow background appears when the most recent past due scheduled doses have been given. When all scheduled administrations have been given, the yellow background appears along with the notation DC and the discontinued date and time. Automatically discontinued medications remain on the MAR screen for 24 hours after the yellow background and the DC notation appear.

v  In Retro MAR, if a medication has scheduled, unadministered doses, it appears on the Retro MAR screen as if were still ACTIVE (that is, without a yellow background and with scheduled administration dates and times in the Last Given column.)

v  When all ordered doses of a scheduled, STAT, or ONE TIME medication have been documented, that medication no longer appears on the Retro MAR screen. All discontinued PRN medications in Retro MAR appear with a yellow background and a status of DC for a period of days specified by your facility. STAT Meds discontinue after 1 minute.

Selecting a Medication

Before you can view or document a medication on any of the MAR routine screens, you must select it, using one of the following methods:

I. Click on the medication with your mouse

2. Press the á and â to move the blue highlight bar through the list of medications.

3. When the correct item is highlighted, press → or click on the Select option.

Administering a Medication

To indicate that the ordered dosage of the medication has been administered, you must document the administration on the Medication Administration Record (MAR) screen. To document an administration, follow these steps.

1.  Select the medication you want to document. The Next Scheduled column indicates the next scheduled date and times to administer this medication. To document against a different date and time, you first need to select a different scheduled administration of this medication.

  1. Click on the Administer option on the MAR menu to administer the medication you selected. Depending on several factors, one or more assessment screens may then appear.

3.  If an assessment screen appears, complete the assessment. Click on the Return option to get back to the MAR screen.

4.  When the administration of the medication has been documented, a checkmark appears next to the selected medication and the date and time of administration appears in the Last Given column.

5.  To save this information, you must file the change. If you want to discard your changes before filing, click on the Undo option on the MAR menu.

*** IV documentation on the MAR is done at the time that the bag is hung! Change flow rates at this time. All other IV documentation should be done on the IV Assessment in PCS et

Pharmacy.

ANK Medications are medications which are not verified by pharmacist. Once a pharmacist acknowledges that medication ANK will be removed. ANK medications can be given before pharmacist verification.

Entering A Comment

Enter an administration comment to provide additional detail about the administration of the medication. To enter an administration comment for a medication, follow these steps.

1.  Select the medication for which you want to enter an administration comment.

2.  Click on the Administration Comments option on the MAR menu. The Enter Administration Comments screen appears. (See the graphic below)

3.  Enter the administration comment for the medication. For reference, the medication for which you are entering a comment appears at the top of the screen.

4.  When you are finished entering the administration comment, click on the OK button to save the comment for filing and return to the Medication Administration Record screen. To return to the Medication Administration Record screen without saving your comment, click on the Cancel option.

5.  To save the administration comment, you must file the change. If you want to discard this information, click on the Undo option on the MAR menu.

Entering a Non-Administration Reason/Comment

Enter a non-administration reason to provide an explanation of why the medication was not given. When you do this, you choose a reason from a facility-specific list of non-administration reasons.

To enter a non-administration reason for a medication on the PCS Medication Administration Record screen, follow these steps.

1.  Select the medication for which you want to enter a non-administration reason

2.  Click on the Non-Admin Reasons option on the MAR menu. The Non-Administration Reasons Screen appears.

3.  From the list of non-administration reasons, select the reason that mostly closely describes the reason why the medication was not given. For reference, the medication for which you are entering a non-administration reason appears at the top of the screen.

4.  After you select a reason, the system adds the non-administration reason to the record and you return to the Medication Administration Record screen. A checkmark appears next to the selected medication.

5.  To save the non-administration reason, you must file the change. If you want to discard this information, click on the Undo option on the MAR menu.

Note: If an assessment screen exists for this medication, the assessment screen appears when you select a non-administrative reason. You can enter data on the screen, if appropriate. Your non- administrative reason then files to PHA and EMR along with the assessment screen information.

For example, if you decide not to administer a scheduled dose of Digoxin, a heart rate assessment screen might appear.

Adjusting a Dose

Before you administer a medication it may be necessary to adjust the original ordered dose. To do this, follow these steps:

1.  Select the medication for which you want to adjust the dose.

2.  Click on the Adjust Dose menu option. The Adjust Dose screen appears. (See the graphic below.)

3.  Enter the dose to be administered and click on the OK <F12> button to save the change for filing and return to the previous screen. Click on the Cancel button to return to the previous screen without saving any changes.

*** When administering sliding scale insulin- choose to adjust the dose if the order is in a range (120-150 give 2 units). Otherwise, it may get missed when it flows to the EMR.

Changing the Next Scheduled Time

When you document the administration of a medication (using the Administer option), you document against the date and time displayed in the Next Scheduled column. If you want to change the date and time displayed in this column, follow these steps:

1.  Select the medication for which you want to change the time you are documenting against.

2.  Click on the Schedule option on the MAR menu. The Schedule screen appears, displaying the scheduled administrations of the medication for the next 24 hours.

3.  On the list of scheduled administrations, double-click on the one you want to document. This administration is then highlighted in black with a checkmark appearing to the left of the date.

4.  To save the change of next scheduled administration, click on the Return option. When you return to the MAR screen, the Next Scheduled column is updated to the administration you selected. You can now document the administration of this medication.

Viewing Medication Information

Viewing the Schedule (MAR)

View the schedule to see when the medication is to be administered during the next 24 hours. When you view the schedule, you can also change the next scheduled administration time for this medication.

To view the schedule for a medication, follow these steps.

ü  Select the medication for which you want to view the schedule.

ü  Click on the Schedule option on the MAR menu. The Schedule screen appears.

ü  When you are finished viewing the schedule, click on the Return option to return to the MAR screen.

Viewing the Dose Instructions (MAR)

View the dose instructions to see the instructions for administering the dose of the selected medication. Dose instructions may be entered for zero dose and compound orders. To view the dose instructions for a selected medication, follow these steps.

Ø  Select the medication for which you want to view the dose instructions.

Ø  Click on the Dose Instructions option on the MAR menu. The Dose Instruction screen appears.

Ø  When you are finished viewing the dose instructions, click on the Return option to return to the MAR screen.

Viewing or Entering/Editing Label Comments (MAR)

Choose the Label Comments menu options to see (and possibly edit) comments or instructions about administering the selected medication. Label comments may be entered for medication orders.

The Label Comments options are not available if no label comments exist for the medication and your parameters do not allow you to enter or edit comments. In all other cases, one of the following three menu options appears:

View Label Comments -appears only if comments exist for the medication and users are not permitted to enter or edit label comments. To use this menu option, do the following:

v  Click on a medication to highlight it.

v  Click on the View Label Comments menu option.

v  After you view the comments, click on either the OK or F12 button or the Cancel button at the bottom of the window to return to the MAR.

Viewing the Drug Monograph (MAR)

View the drug monograph to see additional information about the selected medication. The drug monograph may include information such as the medication's common uses and instructions on how to administer it. To view the drug monograph for a selected medication, follow these steps.

**** USE FOR PATIENT EDUCATION****

v  Select the medication for which you want to view the drug monograph.

v  Click on the Monograph option on the MAR menu. A list of monographs for the selected medication will appear.

v  Select the monograph you wish to read.

Viewing the Allergies (MAR)

You can view an individual's allergies to see a list of medications, foods, or other substances for which the person is known to be allergic. This allergy information is based on the following:

v  medication allergies recorded in the Pharmacy (PHA) Enter/Edit Patient Data Routine

v  any allergies recorded in the Order Entry (OE) Enter/Edit Patient Data

v  allergies entered via the Allergy Management feature in PCS.

Note: Pharmacy orders entered in PCS are checked for allergies when the Pharmacy module receives them. If you order a medication to which the person has a known allergy, the order is rejected in Pharmacy.