4.2. The rules for documenting medications
- The Medication Administration Record (MAR) is a legal document. Documentation must be accurate.
- The document immediately after giving or monitoring medications, not before.
- Document each administration or monitoring at the time
- Only document medications that you administer or monitor.
- Initial medications are given or monitored in the box for the corresponding date and time.
- Always use black ink, never use a pencil
- Never use white-out or attempt to erase an error
- Not documented, not administered/monitored
- No blanks on the MAR