Record keeping in care work is very important and any mistakes on a paper record can create serious risk to the people we support.
Complete the MAR Sheet at the Time
Record medication administration at the time of administration on the MAR sheet, include the time in the space provided, sign in the appropriate box and use a code agreed with others involved to record refused or withheld doses.
Correcting Mistakes on Paper Records
Any corrections or amendments to entries in care records must not be carried out using correction fluid. Instead, draw a single line through the error and add the correct information to the side of the line. This must include your initials and the date.
What Counts as a Complete Entry A useful reference for Safe handling of medication is tidaltraining.co.uk/health-and-social-care-courses/safe-handling-of-medication-training/.
The Safe administration of medicines is reliant upon an accurate and complete Medication Record being kept by Care workers. Each entry on the Medication Administration Record should contain: the date, time given, the dose of the medication administered and the Care worker’s signature.
Storing and Auditing Records
The completed MAR Sheet must be kept for a minimum of 3 years from date of completion. Care workers, Managers and inspectors must refer to the adult social care medicines management standards in relation to record keeping, safe storage of records, accessibility and audits. A check should be completed on a monthly basis to ensure that all relevant information has been entered and that there are no unusual gaps or patterns in recording.
Getting Formal Training
Good record keeping can help protect the people you support, as well as yourself.
