Medication administration record: what belongs on it and what a gap means

A medication administration record is the document on which every dose given to a person is recorded, at the time it is given, by the person who gave it. In the UK the same document is usually called a MAR chart. It is used in care homes, domiciliary care, hospitals, schools and camps, and it is the first record any inspector, investigator or family member asks to see when a question arises about medicines.

Its purpose is narrow and serious: at any moment, anyone should be able to look at it and know whether a dose was given, refused, withheld or missed, and by whom. Everything else about the design of the form follows from that requirement.

What a medication administration record contains

• The person’s identifying details and, where the setting uses one, a photograph, plus known allergies displayed prominently.
• Each medicine as prescribed: name, form, strength, dose, route and the times or frequency.
• Start and stop dates, and the prescriber, for each item.
• A grid of administration slots, one signature box per dose per day.
• A code key for anything other than "given" — refused, withheld, not available, hospital, self-administered, spat out — printed on the chart itself rather than kept in someone’s head.
• Space to explain a coded entry, because the code says what happened and the note says why.
• Special instructions: with food, before food, crushed, applied to which site.
• For as-required medicines, the indication, the maximum in twenty-four hours and the minimum interval — plus a record of whether it worked.
• The signature of the person administering, and a specimen signature list so initials can be identified later.

A gap is not a small problem

The most common finding in medicines audits is a blank box, and the reason it is treated seriously is that it cannot be interpreted. It might mean the dose was given and not signed for, or that it was missed. Both are possible, only one is safe, and nobody can tell which from the record. That is why the discipline is to sign at the point of administration rather than at the end of a round, and why codes exist for every outcome including the awkward ones. A chart with honest refusal codes is a better record than a chart of unbroken signatures.

Never alter an entry by overwriting it. Corrections are made by a single line through the error, initialled and dated, with the correct entry alongside — a record that has been tidied is a record nobody can rely on, and in an investigation an amendment that hides the original is worse than the original error.

Handwritten additions and the transcription risk

Charts printed from the pharmacy are safer than charts written by hand, because transcription is where the wrong strength and the wrong frequency enter the record. Where a handwritten addition is unavoidable — a mid-cycle change, a short course — the widely used safeguard is that a second trained person checks and signs the entry against the prescription. Treat every handwritten line as a place an error can start, and reduce the number of them rather than the care taken over them.

Retention and the surrounding file

Completed charts are retained for a period set by your regulator and are read alongside the rest of the medicines file: the policy, the competency assessments of the staff who administer, the audits, the incident records — including any moved onto an electronic medication administration record — and the record of medicines received, carried forward and disposed of. Ettex Records keeps that file per person and per service with the retention dates visible, Ettex Forms collects the medicines audits and competency checks, and Ettex Docs holds the policy with version history so the version in force at the time of an incident is recoverable.

To be direct, and this matters more here than elsewhere on this blog: nothing we make is a medication record system, and none of this is clinical or regulatory advice. The chart itself belongs in a purpose-built system or on the pharmacy-printed form, with the clinical safeguards those carry. What a documents-and-records tool holds is the paperwork around it — policy, training, audit, retention.