Name: Month: Year:
Allergies: CLI Health & Wellness Coordinator: AFH:
Medication Orders / Time / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24 / 25 / 26 / 27 / 28 / 29 / 30 / 31
Name, Dosage, Route:
Reason:Name, Dosage, Route:
Reason:Name, Dosage, Route:
Reason:Name, Dosage, Route:
Reason:Name, Dosage, Route:
Reason:Medication Orders / Time / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24 / 25 / 26 / 27 / 28 / 29 / 30 / 31
Name, Dosage, Route:
Reason:Name, Dosage, Route:
Reason:Name, Dosage, Route:
Reason:Name, Dosage, Route:
Reason:Name, Dosage, Route:
Reason:Staff Signature / Initial / Signature / Initial /
Signature
/Initial
Resident Name: / Month: / Year:If medication not administered, enter an “X” in the time scheduled. Then provide additional information using the codes in the box at the left in the record below
Comments – Reason Medication Not Given
Date/Time / Reason (Select Code) / Comments/Explanation / Staff Initials
<Select>12345678
<Select>12345678
<Select>12345678
<Select>12345678
<Select>12345678
<Select>12345678
<Select>12345678
<Select>12345678
<Select>12345678
<Select>12345678
<Select>12345678
<Select>12345678
<Select>12345678
<Select>12345678
<Select>12345678
1
Adapted from APD Form 65G7-00, adopted 3/10/08 by Rule 65G-7.001(13) 2/16/2017
PRN (As Needed) Medication Administration Log
Initial Medication as given on MAR and complete as directed below:
Name: Month: , Year:
Allergies: CLI Health & Wellness Coordinator:
AFH:
DATE/TIME / MEDICATION NAME, DOSE, & ROUTE / REASON MEDICATION GIVEN / RESPONSE TO MEDICATION(What effect(s) did it have for the resident?) / STAFF INITIALS
1
Adapted from APD Form 65G7-00, adopted 3/10/08 by Rule 65G-7.001(13) 2/16/2017
Directions for Use – MAR and PRN Log
The Medication Administration Record (MAR) should be set up at least monthly and updated with any medication changes by staff trained in medication management. The MAR should always be double checked to ensure accuracy.
The MAR should list all Scheduled and As Needed or PRN medications:
· Each scheduled medication should include the medication name, dosage, route, and administration time(s) as ordered by the resident’s medical provider. Please also include why the medication is being prescribed for the resident (reason) and possible side effects of the medication so staff can monitor for these effects.
· All As Needed or PRN medications should include medication name, dosage, route, and administration directions for as needed administration. Please also include why the medication is being prescribed for the resident (reason) and possible side effects of the medication so staff can monitor for these effects.
Complete MAR Form EACH DAY. Enter your initials in box immediately after medication administration.
Complete PRN (As Needed) Log immediately after PRN medication administration, include full medication name, date and time of administration, the reason for administration, and staff initials. After 30 minutes, check with the resident and document the resident’s response to the medication. Did the resident respond as expected with the medication indication?
Submit this form to the member's CLI office by the 5th of the following month via fax, postal mail, or drop off:
Blair / / 608-785-5331 / PO Box 167, Blair, WI 54616
La Crosse / / 608-785-6315 / 1407 St. Andrew St., Suite 100, La Crosse, WI 54603
Mondovi / / 608-785-5332 / 697 East Main St., Mondovi, WI 54755
Neillsville / / 608-785-5333 / PO Box 190, Neillsville, WI 54456
Sparta / / 608-785-5330 / PO Box 254, Sparta, WI 54656
1
Adapted from APD Form 65G7-00, adopted 3/10/08 by Rule 65G-7.001(13) 2/16/2017