MAR, eMAR and clear records

A medicines administration record (MAR) shows what medicines were given or supported. An eMAR is the electronic equivalent. Both need to be accurate, secure, up to date and completed promptly after administration.

CQC guidance for England says good record keeping protects people receiving medicines and the staff who support them. Whether paper or electronic, records should be legible, clear and accurate, signed by the staff member involved, show the correct date and time, be completed as soon as possible after administration, and record both medicines taken and refused.

What good MAR or eMAR practice includes

• Person details: full name, date of birth and any other identifiers required by local policy.
• Medicine details: name, formulation, strength, dose, route, frequency and any special instructions.
• Allergies: known allergies and previous reactions should be visible and acted on.
• Timing: record the exact time or the time of day required by local policy, especially for time-sensitive medicines.
• Separate records: cross-reference warfarin, insulin, topical charts, patch charts or other specialist records where used.
• Changes: handwritten changes should only be made or checked by trained, competent staff and only in line with policy.
• Visiting professionals: if a nurse or other professional gives a medicine, the record should show this to avoid duplicate dosing.

A medicines record should show exactly what happened. Never alter a MAR or eMAR by guessing.