March 2010

Medication Medication Administration Record Administration Record

(MAR)(MAR)

• Describe the Medication Administration Record – Steps to implementation– Menu Options– Medication Order Challenges– Tools

• Identify common pharmacy issues

Course Objectives

• Why implement computerized MARs?• Forces adoption of inpatient med order entry (IOE) and

configuration of inpatient system parameters• Foundation for implementation of CPOE in EHR

• Benefits of computer-generated MAR • Reduces or eliminates transcription by hand• Legibility• Allows all staff to view inpatient’s meds on-line• Allows use of multiple tools & reports

Overview

Overview - continued

• Impacts all disciplines• Ward Clerks• Providers• Nurses• Pharmacists/Technicians• Respiratory Therapists

• Requires multi-disciplinary cooperation

Types of Printers and

Terminal Types

• Newer printers preferred

– Very Challenging - need IT help.

– Printer requirement: 132 columns

• Terminal Type Examples

Types of Labels

• Labels• Company: TimeMed• Phone Number: 1-800-323-4840• Item Number: DPS15-32A

• DAPO Discontinue All of a Patient's Orders• EUP Edit Inpatient User Parameters• ESD Edit Patient's Default Stop Date• HAPO Hold All of a Patient's Orders• IOE Inpatient Order Entry• IPF Inpatient Profile• INQ INQuiries Menu ...• LPUD Label Print/Reprint• NV Non-Verified/Pending Orders• OE Order Entry• PICK PIck List Menu ...• PPUD PAtient Profile (Unit Dose)• REPM Reports Menu ...• SUPM Supervisor's Menu ...

RPMS MAR Options

MAR Parameters

• Ward Group Set up

• Inpatient User

• Inpatient Ward

• Systems Parameter

New Workflow

• MAR Labels– Who prints and who sticks?– Can be configured to print automatically

• This may generate unnecessary labels• May be advisable to print “on demand”

• MAR Sheets– Who prints and who manages?

• The MAR consists of 2 types of sheets:– Continuous MAR sheet (aka “Scheduled” meds)– PRN/One-time MAR sheet

• Shows meds given prn, one-time, and on-call

• The schedule type for each order determines which MAR the order will print on

MAR Sheets

Schedule Types

• Not the same as the Schedule– e.g. schedules are “qid”, “qhs prn”, “now”, etc.

• Schedule types– O = One-time (e.g. “stat” or “now” doses)– OC = On-call (e.g. pre-op dose)– P = PRN (no set administration times)– C = Continuous (aka “Scheduled”)

• Usually set administration times

– R = Fill on Request (e.g. creams, inhalers, etc.)• Can be continuous or prn

Schedule Types (cont)

• Inpatient EHR Drug File Prep: Default for schedule type is “continuous”

• Sometimes this will be changed during POE (Provider Order Entry)– Benadryl ordered PRN in EHR by provider

(Q8H PRN), so PRN is now the “schedule type”

– Benadryl ordered continuous in EHR by provider (QHS), so continuous is now the “schedule type”

• Does the pharmacy staff enter these?– Should be entered for complete profile– MUST be entered if drug cannot be overridden

• Should MAR be updated with MAR label?– If urgent need, RN might override Pyxis before

the label is applied to MAR– This can lead to“extra dose” errors

• Should nursing staff handwrite these onto the MAR?

One-Time Orders

Order Verification

• Verification on MAR sheet– Designated space for RN initials on each

order

• Verification in RPMS or EHR– RN should also verify in computer– Skip teaching RN verification in RPMS– Go straight to verification in EHR

Verification of Orders

Printing MAR Sheets

• Can print through two menu options– From Inpatient Order Entry

• for 1 patient, e.g. after entering or finishing all orders for a new admission

– From the Unit Dose Menu, Reports Option• Printing of MARs for multiple patients or for an entire ward

• Option to print Blank, Non-blank, or Both– Blank sheets are used to apply MAR labels for orders

subsequent to admission– If short stay or few med changes, blank sheets go

unused & waste paper (e.g. OB, nursery)

24 hour vs 7 or 14* day MAR24 hour 7 or 14 day

Pros

-New “clean” copy each day-May eliminate need for stickers-Standard at most community hospitals

-No need to print MARs daily-Saves paper-Can look at trends easily, e.g. pain meds past 3 days-Can re-print “prn”

Cons

-Volume of paper-More difficult to look at med admin over time-Who will print MARs each day (or night)?

-Updating of MARs with stickers is time/labor intensive-MARs become “messy” due to changes, discontinuations

*14 day MAR same as 7-day except boxes for documenting are smaller

24 Hour MAR - Continuous

7 Day MAR – Continuous

24 Hour MAR – PRN/One-Time

7 day MAR – PRN/One-time Sheet• ONE-TIME/PRN SHEET 7 DAY MAR • 06/28/2009 through 07/04/2009 SITE: PHOENIX INDIAN MED CTR (606601) • Name: PATIENT,ANY Weight (kg): 127.47 06/26/2009 • Ward: ICU• PID: XXXXXX DOB: 06/23/1963 (46) Height (cm): 156.85 01/24/2005 • Room-Bed: ICU-5• Sex: FEMALE Dx: LEFT CHEST ABCESS Admitted: 06/26/2009 19:00 • Allergies: NKA ADR: • Order Start Stop Order Start Stop• ------------------------------------------------------------------------------------------------------------------------------------• | | | | | |• 06/28 |06/28 10:17 |10/06/09 15:00 (P) | | 06/26 |06/26 21:00 |10/04/09 15:00 (P) • BISACODYL TAB,EC P | | PROMETHAZINE INJ,SOLN P• Give: 10MG PO QDAY PRN | | Give: 12.5MG (IV-MIX W/ 10ML NS) IV Q3H PRN• FOR CONSTIPATION | | FOR NAUSEA• WS RPH: reg RN: _____ | | WS RPH: SMD RN: RNM• ------------------------------------------------------------------------------------------------------------------------------------• | | | | | |• 06/26 |06/26 21:00 |10/04/09 15:00 (P) | | • MORPHINE INJ P | | • Give: 2-8 MG IV Q1H PRN | | • FOR PAIN | | • WS RPH: SMD RN: RNM | | • ------------------------------------------------------------------------------------------------------------------------------------• | | | | | |• 06/26 |06/26 21:00 |10/04/09 15:00 (P) | | • PERCOCET 325/5 U/D TAB P | | • Give: 1 TO 2 TABLETS PO Q4H PRN | | • FOR PAIN | | • WS RPH: SMD RN: RNM | | • ------------------------------------------------------------------------------------------------------------------------------------• |DATE|TIME | MEDICATION/DOSE/ROUTE|INIT| REASON | RESULTS |TIME |INIT|• |--------|--------|-----------------------------------------|------|-----------------------|-----------------------|--------|------|• |--------|--------|-----------------------------------------|------|-----------------------|-----------------------|--------|------|• |--------|--------|-----------------------------------------|------|-----------------------|-----------------------|--------|------|• |--------|--------|-----------------------------------------|------|-----------------------|-----------------------|--------|------|• |--------|--------|-----------------------------------------|------|-----------------------|-----------------------|--------|------|• |--------|--------|-----------------------------------------|------|-----------------------|-----------------------|--------|------|• |--------|--------|-----------------------------------------|------|-----------------------|-----------------------|--------|------|

Reports Menu Options

• From Unit Dose Menu, Reports Option– MARs (already discussed)– Action Profiles– Medications Due Worksheet– Inpatient Stop Order Notices

Reports: Action Profiles

• Action profiles (AP1 and AP2)– Prints all active inpatient meds for a pt– Provider can “take action” on orders

• Renew, Discontinue, or No Change

– Useful for medication reconciliation at patient transfer, post-op, and discharge

– Saves a lot of writing for providers– With E.H.R. these will no longer have any

utility

Action Profile #1

Reports: Medications Due Worksheet

• Used by nurses

• Prints medications due in a selected time frame (e.g. during that nurses shift)

• Allows nurse to meet Joint Commission requirement without having to take MAR to patients room

• “Work Copy”, discard at end of shift

Medications Due Worksheet

Reports: Inpatient Stop Order Notices

• Prints list of medications that are going to expire in a defined time frame

• Can print Unit Dose orders, IV orders, or both

• Useful if your site policy specifies automatic stop order durations

Inpatient Stop Order Notice

• Accu-checks & Sliding Scale Insulin

• Premixed maintenance IV Fluids– Plain and with KCl

• Titrated IV drips (e.g. dopamine)

• Wound dressing orders

• Immunizations

Difficult/Oddball Med Orders

Difficult Med Orders: Sliding Scale Insulin and Accu-cheks

• MAR requires multiple blanks for each time of administration, i.e.– Accu-chek result, dosage of insulin, RN initials

• Requires set up of special standard schedules

• Special schedule is then used in entry of order

Difficult/Oddball Med Orders: Maintenance IV Fluids

• Will these be placed on MAR?

• If so, quick orders are built as “IV Medications”– Appears as an IV “Admixture” in the

pharmacy package– Adjust the number of labels needed each day

for Pre-Mix IV Solutions

Difficult/Oddball Med Orders: Titrated IV Drips

• Entered in IV package as Admixture• Rates of administration often change• In Admin Rate field, enter “TITRATE@3”

– On label, admin rate prints as “TITRATE”– When scheduled labels are run, three labels will print

with “dose due” times spaced 8 hours apart

• In Other Print Info field, can enter special info• e.g. Start at 5mcg/kg/min. Titrate by 2-4 mcg/kg/min q10min

to keep SBP > 90.• This information prints both on the label and on the MAR

Difficult/Oddball Med Orders: Immunizations

• Often ordered to be given once “at discharge”• One-time order dilemma

– Default Auto stop time for all one-time orders must be defined (min 1 day, max 100 days)

– If defined as 1 day, order will auto d/c before pt disch – If defined as longer, all one time orders will continue

to show for that duration (even if already given)

• Solution– during order entry, change stop date to 7 or 10 days

in the future

Recommendations for Implementation

• Develop strategy based on site specific variables– Workload / census, staffing, hours of operation, etc.

• Secure consensus with nurse leadership

• Communicate plans to all

disciplines that are going

to be affected

Nursing Providers Pharmacists Ward Clerks RT’s

Recommendations for Implementation (cont)

• Start in a controlled environment– Pilot on one ward, ideally one with

• Flexible, enthusiastic staff• Limited number of med orders• Limited number of complex med orders

• Evaluate issues and make changes

• Communicate to all parties involved

• Expand to other wards

Training of Staff/Competency

• Attend departmental staff meetings– Show MAR examples, explain general use

• Train nurse educators or nurse managers– Delegate one-on-one training with staff nurses

if possible

• Integrate review of MARs into nurse and provider orientation for new employees

Questions?

Nursing Perspective: MAR

• Nursing Procedures (Daytime)– Medication Administration– Medications Due Worksheet– MAR Kardex

• Nursing Procedures (Evening)– Pharmacy Closed– Pending MAR Labels

Nursing Perspective: MAR

• Nursing Department Involvement– 7 Day/14 Day MAR vs 24 Hour MAR

• Which one?• Location of MAR Label Printer and MAR Laser

Printer

– Verbal/Telephone Order(s) Process

Questions?