A Medication Administration Record (MAR) is a legal document used across all healthcare settings to precisely track and document every medication dose given to a patient. This record serves as an official log detailing the comprehensive history of drug administration. The MAR is a tool for healthcare providers, ensuring a continuous account of the patient’s medication regimen. It is a mandatory part of the medical chart, consulted before and updated immediately after any drug is administered.
The Core Function of the Medication Administration Record
The primary function of the MAR is to act as the definitive source of truth regarding a patient’s medication history. This record links the physician’s written order directly to the action taken by the administering staff member. It creates a closed-loop system for medication management, minimizing the potential for miscommunication or error.
The MAR is necessary for compliance and auditing, serving as legal proof that a prescribed dose was or was not delivered. It must reflect the exact timing and circumstances of administration. This documentation supports the continuity of care by ensuring every member of the healthcare team has access to an up-to-date, accurate record of the patient’s treatment.
Essential Information Contained in the MAR
Every MAR contains specific, standardized categories of information completed for each administered dose. The record includes patient identification, such as the full name, date of birth, and medical record number, to confirm the correct individual is being treated. The MAR also lists the patient’s known drug allergies, serving as a constant safety reminder for the administering staff.
The body of the record details each prescribed medication, including the name, dosage strength, and the route of administration (e.g., oral, intravenous, or subcutaneous). This information is transcribed from the initial prescription order but is organized specifically for the timing of administration. The MAR lists the scheduled times a medication is due, alongside columns for the administering staff member’s initials or signature and the exact time the dose was given.
The MAR differs from the initial prescription order because it focuses on the action of administration rather than just the order. For each scheduled time slot, the staff member must record their initials, confirming the drug was given, or use a specific code to explain why a dose was omitted or refused. This detailed log transforms a static order into a dynamic history of delivered care, including the medication’s start and stop dates.
How the MAR Ensures Documentation Accuracy
The MAR is central to establishing accountability in medication delivery. Before administering any drug, staff members use the MAR to cross-reference the “five rights” of medication: the right patient, drug, dose, route, and time. This real-time verification process is documented immediately after the medication is given, not before, ensuring the record accurately reflects the completed action.
Proper documentation on the MAR holds the administering staff member responsible for the accuracy of the entry. If a dose is missed or an error occurs, the MAR must contain a clear, factual explanation, maintaining a complete record of the medication’s chain of custody. Omissions or incorrect entries can lead to legal issues and compromise patient safety by obscuring the true status of a patient’s treatment.
The MAR also includes space to document the patient’s response to an administered medication, particularly for “as needed” (PRN) drugs. PRN documentation requires notation of the reason for giving the drug and the result. This detail helps the prescribing provider assess the effectiveness of the treatment plan, and the requirement for a clear signature ensures accountability is traceable to a specific person.
Transitioning from Paper to Electronic Records
Historically, the MAR was a paper-based chart (pMAR) that was manually updated, but modern healthcare increasingly relies on the Electronic Medication Administration Record (eMAR). The transition to eMAR systems has significantly improved medication safety by eliminating problems like illegible handwriting and transcription errors. The electronic format integrates directly with the patient’s broader Electronic Health Record (EHR), creating a unified and easily accessible data set.
A major improvement of the eMAR is its ability to provide real-time updates across the entire care team. A medication change made by a physician is immediately visible to the nurse preparing the dose. These electronic systems also incorporate safety features, such as built-in alerts that flag potential drug-to-drug interactions or doses outside of a safe time window. EMARs often utilize barcode scanning technology to confirm the medication package matches the patient’s wristband and the order, adding a layer of verification at the point of care.