The Importance of Medication Records

What are medication records?

Aster Care has an excellent track record in administering complex medication with no reportable errors. We have learned from our extensive experience and developed additional training and systems to plug any gaps we have come across, to now have a process that includes modular training, on site training, competency assessments and further practical classroom training to understand the MAR in more depth. 

This brings us to the importance of medication records. These include a range of documents in addition to the MAR (actual details of drug, dose, time, route), including the initial needs assessment (determines the support required), the care plan (to instruct the care worker of their responsibilities) and the daily notes (any changes/issues on the day). All of these documents are important in recording what is to be given, how it is to be given and when, in order to ensure the whole process of administering medicines is safe.

Why have medication records?

There is a legal requirement under the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 to keep medication records. Quite simply, having a record of all the medication to give and when means our staff don’t have to remember what medication to give! We can also see what is being given regularly and what is not, This information can be useful when speaking to health professionals and reviewing the effectiveness medication. 


What happens if we don't keep accurate records?

There are many things that can go wrong if we do not keep accurate records such as:-


  • The wrong medication may be given.
  • Double doses can be given/doses may be entirely omitted.
  • Too much or too little medication may be given. 
  • Refusals may go undocumented.
  • The person may run out of medication.
  • The person may become ill if the medication is given erratically.
  • Too much/too little medication may be given.

How we avoid errors

We train our staff PRIOR and DURING their probation period, and ensure they are safe to administer medication before they are left to work alone. As an additional measure, our person-centred approach means staff will receive training with each service user to know their tailored regime.  Staff are also taught the following:-

The 5 Rights: 
Check the following always after reading the MAR:-
  • Right Person
  • Right Medication
  • Right Time
  • Right Dose
  • Right Route

In addition:-

  • Always check on handover what medication has/hasn’t been given, and whether any changes have been noted in the communication book.
  • ALWAYS read the MAR chart before administering. Do not assume nothing has changed since your last visit.
  • Gain consent from the service user (refer to care plan for those who are unable).
  • DO NOT sign the MAR chart until AFTER the medication has been taken.
  • Use your initials to sign for the medication.
  • Record any relevant additional information in the communication book.
  • If the medication itself or the MAR chart is unclear, do not proceed but ask the office.
  • Ensure any PRN medication is spaced out in accordance with the instructions.

How it is all brought together

The MAR chart is the bible for giving safe medication. When this is followed correctly, few errors should occur. In practice, the only errors we may see may be someone forgetting to sign the MAR chart, but systems are in place for this to be reported promptly to avoid double dosing or missed tablets.  

If you require any further information on how we can help, please contact us via the following link