mar - medication administration record mak units only created 10/04
TRANSCRIPT
MAR - MEDICATION MAR - MEDICATION ADMINISTRATION RECORDADMINISTRATION RECORD
MAK UNITS ONLYMAK UNITS ONLY
Created 10/04Created 10/04
KEY COMPONENTSKEY COMPONENTS
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
LEGEND AND SYMBOLSLEGEND 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
LEGEND AND SYMBOLS – cont’dLEGEND 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
CHARTING REASON AND CHARTING REASON AND EFFECT SECTIONEFFECT SECTION
Supplemental Section of MAR Provides additional charting data
Reason Documented reason med administered or not
administered Effect
Documented effectiveness for administered med
CHARTING HISTORY CHARTING HISTORY SECTIONSECTION
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
OTHER INFORMATIONOTHER INFORMATION
PATIENT INFORMATION Patient Identifiers Allergies
NURSING ELECTRONIC SIGNATURES
MAR IMPORTANT FACTSMAR 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
MAR HEADERS, MAR HEADERS, SECTIONSSECTIONS
AND AND ORDER DETAILSORDER DETAILS
EXAMPLESEXAMPLES
LAYOUT OVERVIEWLAYOUT OVERVIEW
MED or IV MAR Header
MAR Date Range
Order Details
Section Header Based on Order
Status
Charting Date
Section Divider
ORDER DETAILS OVERVIEWORDER DETAILS OVERVIEW
Dosage, Strength, Route and Frequency
Start/Stop Date and Time
Brand/Generic Name
Order Divider
Charting Information
ROUTINE ORDERSROUTINE ORDERS
Routine (Scheduled)
Orders
Chart Date
Order Information
Charting Information
STOPPED/DISCONTINUED STOPPED/DISCONTINUED ORDERSORDERS
Stop date occurred in MAR date range
Stop Date/Time
Section Header Based on Order
Status
STOPPED DISCONTINUED STOPPED DISCONTINUED ONE TIME ORDERSONE TIME ORDERS
Stopped or Expired One Time Orders
Start Stop Date are Equal
PRN ORDERSPRN ORDERS
Active Order No Charted Occurrences
Order Section Header
PRN PRN STOPPED/DISCONTINUEDSTOPPED/DISCONTINUED
Order Section Header
Not Charted During MAR Date Range
Order Start/Stop Date
FUTURE ORDER NOTATIONFUTURE ORDER NOTATION
Start Date in Future at Print Time
REVIEW – MEDICATION MARREVIEW – MEDICATION MAR
REVIEW - IV MAR REVIEW - IV MAR
LEGENDS AND LEGENDS AND SYMBOLSSYMBOLS
EXAMPLESEXAMPLES
CHARTING STATUS REVIEWCHARTING STATUS REVIEW
Order Section Header
NOT CHARTED – Time w/o any other
information
NOT ADMIN – asterisk (*) f/b
Time and User ID
ADMIN – Time and User ID
HIST – Revision Details for Charted
Occurrence
M = CHARTING DATA M = CHARTING DATA COLLECTIONCOLLECTION
Vital Sign, Blood Sugar or Pain Scale
Information
FREE TEXT DOSAGE AND FREE TEXT DOSAGE AND SITESITE
Administration Site
Free Text Dose Entered (D=)
Vital or Blood Sugar (BS) and or Pain
Scale (PS)
CHARTING CHARTING REASON/EFFECT AND REASON/EFFECT AND
HISTORYHISTORY
EXAMPLESEXAMPLES
CHARTING REASON AND CHARTING REASON AND EFFECTEFFECT
Section Header
Med, Occurrence Date/Time, Chart
Time, User ID
NOT ADMIN Reason
PRN Reason
CHARTING HISTORYCHARTING HISTORYSection Header
Order, Occurrence Date/Time, Charted
Date/Time and Revised Data Element _ OLD
Post – Revise, New Charted Date/Time and Revised Entry
Value
MAR REVIEW IMAGE file MAR REVIEW IMAGE file contains MAR document contains MAR document
images. Please review this file.images. Please review this file.
THANK YOU!THANK YOU!