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Maintaining accurate medication administration records (MARS) is a vital nursing responsibility, both for legal reasons and for patient safety. The liability risk of the healthcare provider may increase if medication administration isn't properly documented. Missing or inaccurate documentation can lead to drug errors that may jeopardize your patient's health.


Record-keeping systems

Two main types of MAR systems are used today: the MAR and computer charting.


The MAR

The MAR is an Harvey-ch008-inequat001.jpg form that goes into the patient's chart. It tracks what medications are currently ordered, when medications are given, as well as important information such as allergies. An MAR also may be kept in the medication room on the medication cart in a three-ring binder or may be attached to the patient's chart or clipboard while the patient is hospitalized. On discharge, the MAR is placed in the patient's chart with the other MARs already used for that patient.


Computer charting

Another system, computer charting or electronic medication administration record (eMAR), is being used increasingly by more healthcare facilities. Information is entered into a computer that automatically generates a list of administration times for all scheduled medications. Computer systems cut the risk of drug errors caused by illegible hand writing, therefore improving patient safety (See Record keeping in the computer age).


See you in court

No matter what type of medication charting system your facility uses, you must still record certain stand ard information. Stand ardization allows medication administration records to be used as legal documents if it ever becomes necessary to prove that a drug dose was or was not given. (See Different forms, same info.) As a rule of thumb, chart it to prove it. In other words, if you're being questioned under oath about a situation 5 years before, will you remember every drug you gave that patient? Probably not very clearly. This is yet another example of the importance of proper documentation!