Record keeping

This presentation is going to take you through the legislation and guidance around health records and confidentiality and record-keeping in relation to medication confidentiality is extremely important each professional involved in the care of an individual will be constrained by the laws surrounding confidentiality, you cannot discuss any aspect of a resident’s care or medicines with anyone other than the care home manager, the residents GP, pharmacist, other health care professionals involved in the care or individuals who have power of attorney. You must be careful not to pass on any information about the resident to friends and family unless you have the resident’s permission to do so.

Under the access to health records Act 1990 residents can request access to their health records, a request must be made in writing and time allowed to prepare the record. The Data Protection Act gives legal rights of the residence and respects or personal information that is held above them in the care setting, the Act covers the collection storage and sharing of information. The management code of practice for Health and Social Care 2016 states that records including patient medication records should be kept for eight years after the end of care.

If you have any doubts about what information can be shared with whom or would you have any requests for personal information from a resident or their representative refer them to your care home manager. So now let’s have a look at medicines administration records. The Health and Social Care Act outlines that care home providers have a legal duty to maintain accurate records of care given to residents. Information that is stored about the resident will include their medicines administration records so they are subject to the data protection act as such all data should be accurate and kept up to date.

Medicine administration records are also known as MARs or MAR charts and they are the formal record of administration of Medicine within the care setting. MAR charts should include all prescribed and externally applied medicines the MAR should enable you to record all prescribed medicines and homely remedies given to a patient. MAR charts should contain clear instructions. If a MAR has instructions when required whilst directed, the care setting needs to know what this means and it should be documented so all carers who administer medicines are clear when these medicines should be given. MARs can be electronic or paper, printed Mars have preferred to handwritten because they reduce the chance of transcription errors and are easier to read.

So what is included on a MAR chart?

A medicine administration record should detail for each person: what is received, the MAR should include the name, form, strength and quantity of medicine supplied. It should show you what is currently prescribed including for those who self administer medicines, the MAR should be a complete list of all medicines that are prescribed, even patients who self administer their own medicines should have a MAR it should also document what is given by care workers. When you have confirmed the resident has taken a medicine you should initial the appropriate box on the MAR. CQC standards require MAR charts to be completed immediately after administration by the person who has administered the medicine.

a MAR should also tell you what is being disposed of, there are a number of reasons why a medicine may need to be disposed of, the resident may have refused to take the medicine, the medicine could have been dropped, it could have been discontinued by the prescriber. It is necessary to document on the MAR what has been disposed of, so here we have some examples of printed MAR charts, you can see that the MAR contains the resident’s name, address and date of birth. It also identifies the resident’s allergy status and their GP, it also contains the name and dose of the medicine prescribed. The time of day to administer it is also identified.

Under the name of the medicine you will occasionally see special information about the medicine, this may relate to the specific time to administer the medicine. So let’s have a closer look at a MAR chart. MDS and MAR work on a 28-day cycle, the example shown shows the day in the cycle, so days 1 to 28 and also includes a partial date, so this one started on the 9th of December. If today were day 1 week 1 of the cycle, I would confirm the patient’s identity, obtain their consent, administer the dose then initial here to say that the dose had been given.

At the bottom of the MAR there are a number of short codes that can be used to annotate if there been an issue to an administration of the dose. The patient may have refused the medication, they may have felt sick, the patient may be in hospital. On the back of the MAR there is space for carer’s notes so more detail can be added. They can document the reason for any missed doses or describe any other issues.

Care home staff should record the circumstances and reasons why your resident refused a medicine (if the resident will give a reason) in the residents care record and medicine administration record, unless there is already an agreed plan of what to do when the resident refuses their medicines. If the resident agrees, care home staff should tell the health professional who prescribed the medicine about any ongoing refusal and inform the supply and pharmacy to prevent further supply to the care home. There may be occasions when a prescriber makes changes to a medicine mid-cycle, when this happens appropriately trained care home staff are responsible for making changes to the MAR chart.

There should be a policy in the care setting that outlines the procedure in these instances.