MAR documentation guidelines for group homes.

01 · Medication records

What the MAR is for.

A MAR, on paper or electronic (eMAR), lists each medication with its dose, route and scheduled times, and gives staff a place to record what happened at each time. It is part of the person's legal record.

It does three jobs: it tells the next staff member what has already been given, it shows the nurse or prescriber how the person is responding, and it proves to reviewers and payers that medications were given as ordered.

• Person's name, photo if your policy requires it, and allergies.
• Medication name, strength, dose, route, frequency and times.
• Prescriber, start date and stop date, and special instructions.
• A legend of staff initials with full names and signatures.
• Codes for doses not given, defined on the form.

03 · Medication records

Follow the rights of medication administration.

Most training programs teach the "rights" checked before every dose. The traditional five are the right person, medication, dose, route and time. In 2021 the American Nurses Association expanded the framework to eight, adding the right documentation, reason and response.

In many states, unlicensed staff such as DSPs may give medications only after completing a state-approved course, and sometimes only under a nurse's delegation. Know what your state allows before anyone passes medications.

• Right person: confirm identity the way your policy requires.
• Right medication, dose and route: compare the label with the MAR.
• Right time: give within the window your policy allows.
• Right documentation: record it right after the person takes it.
• Right reason and response: know why it is given and watch for effects.

05 · Medication records

PRN (as-needed) medications.

A PRN order should say what the medication is for, the dose, the minimum time between doses and the maximum in 24 hours. Before giving one, check the reason matches the order and when the last dose was given.

Record the time, dose, the reason in observable terms and, at the follow-up time your policy sets, whether it worked. Example: "10:20 a.m. Acetaminophen 500 mg by mouth for headache; L. said 'my head hurts, a 6.' 11:20 a.m. recheck: L. said 'it's a 2' and returned to her puzzle."

07 · Medication records

When a medication error happens.

Common errors include a missed dose, the wrong dose, time, person, medication or route, and documentation errors such as a missing initial. If you find one, check on the person first, call the nurse or prescriber and follow their instructions, then complete the incident report your policy requires.

Under federal Medicaid rules for HCBS waivers, a medication error that leads to a call to poison control, an emergency department or urgent care visit, a hospitalization or death is a critical incident that states must require providers to report. Do not correct the MAR to hide an error; record what happened.

09 · Medication records

What are the most common MAR documentation errors?

The most common MAR errors are blank boxes, charting before the dose is given and orders that do not match the MAR. Most can be caught with a careful check at each shift change.

Each one matters because the MAR is the only record of what the person received. A blank box leaves the next staff member unsure whether to give a dose, and a reviewer cannot tell whether the person missed it.

• Blank boxes with no initial and no code.
• Initials entered before the dose was given, or by someone who did not give it.
• Initials that are not on the MAR's signature legend.
• Codes for missed doses that are not defined on the form, or no reason written.
• PRN doses without a reason or without the result.
• Discontinued medications still listed as active, or new orders not yet added.
• Transcription errors in dose, time or route.
• Entries written over, scratched out or covered with correction fluid.

11 · Medication records

How do you handle a new or changed medication order?

Get the order in writing from the prescriber, have it checked and transcribed before the first dose, and tell every staff member who will pass medications that day. Who may accept a verbal or phone order depends on your state's rules and your agency's policy.

When a dose changes, do not overwrite the old line. Discontinue it with the date and time, then add a new line for the new order. Separate the old supply so it is not used by mistake, and handle it under your disposal procedure.

• Notify the nurse and send the order to the pharmacy.
• Add the new line with start date, dose, route, times and the reason for use.
• Discontinue changed or stopped medications with the date, time and your initials.
• Have a second person or nurse check the transcription against the order and label.
• Brief each shift on the change and any new side effects to watch for.
• Update the person's plan if the change affects their supports.

13 · Medication records

What should you document when a medication runs out or is not available?

Record the dose as not given, using your MAR's code and the reason, and notify the nurse or prescriber right away. A dose missed because the supply ran out is still a missed dose, and many agency policies treat it as a medication error.

Call the pharmacy, write down who you spoke to and when the medication will arrive, and pass that on at shift change. Prevent repeats by checking supplies on a set day each week and reordering before the last few doses.

Sources

Check the official source.

Requirements change and differ by state. Confirm current rules with your state agencies and payers.

• NCBI Bookshelf: Nursing Pharmacology, legal and ethical considerations
• 42 CFR 441.302(a)(6): critical incidents, including medication errors