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