Caregivers Are from Venus but Medical Administration Records Are from MARS

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1.5- Approximate time required: 90 min. 

Educational Goal: 

To provide instruction and motivation to properly fill out and use the medication administration record system.

Educational Objectives:

1. List the reason why a MARs should be filled out properly

2. Provide instruction on how to fill a MARs out.

3. Discuss some principles of dispensing medication

Procedure:            

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Disclaimer

  The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. The information in this article is not meant to supplant training provided by any government agency.

 

Caregivers Are from Venus but Medical Administration Records Are from MARS

 

     One of the most hated chores of residential caregiving is filling out the MARs, or medical administration records. To a lot of caregivers, it seems so tedious, so unnecessary and so unfamiliar. Such feeling are understandable.  Before professional caregiving, you never had to keep track of when and why you gave medication.  You never had to worry about keeping records and being accountable for every little thing. Admit it, some of you look at the MARs and prescriptions and think they are written in an alien dialect. It’s almost as if caregivers are from Venus and those who print medical administration records are from Mars. (Pun intended.)

     Seriously though, filling out the MARs does require a different way of thinking that is unfamiliar to most new caregivers. Often this leads to neglected records. When push comes to shove, the forms are hurriedly filled in all at once.  I admit that I have felt that way, too, in the past.  But the longer I am in the trenches of the healthcare battlefront, the more I have come to appreciate this often underutilized and unappreciated caregiving tool.  That’s right, I said caregiving tool. A tool that, if used correctly, can improve the health of those you care for, make your communications easier and clearer, make your job easier and more organized, and protect you and your clients from harm and legal action.

     So let’s start to change the way you think about the MARs. Let’s align our minds with the principles and reasons behind record keeping. I think that once this is done, you will start to see the benefit of keeping good MARS, and it won’t seem like such an alien way of doing things.

 

Principle No. 1: You have to. It’s legally required.

     Like it, love it, leave it, or lump it, it doesn’t matter. You still HAVE to do it. It’s the law. Those who regulate the industry are going to check to see if you have done it and have done it right. If you want to make a living as a caregiver, then you have to do it- period. It will be of NO use to complain or make excuses. No one will listen, so don’t even try.  Not keeping records is NOT an option.  Now that’s out of the way, we can move on.

 

Principle No. 2: It’s a legal document, admissible in court.

     Caregiving, and healthcare in general, is a very powerful profession. You are intimately involved in the welfare of another individual. When things go wrong, you can be held legally accountable for your actions or the lack thereof. Caregiving is one of those professions where every single working day you could get sued, fined, or even jailed when bad things happen.  It doesn’t even have to be your error. You could potentially be held responsible for not catching and preventing someone else’s mistake.

     A very important message that you must understand in this principle is, if it wasn’t written down, it didn’t happen. That will automatically be the belief of any government inspector, and that will certainly be the position of the lawyers in court.

     The best way to protect yourself from liability is to document what you do. When you stand up in front of a government inspector or a courtroom judge and say, “It wasn’t my fault,” you will be believed more often if you can say, “It wasn’t my fault and here are the records that prove it.”  Think of the MARS as a protective insurance policy that doesn’t cost anything.

     For employees who are reading this article, filling in the MARs is a protection from being fired.  Remember, the owner is going to take the same position as an inspector. If it wasn’t written down, it didn’t happen.  Your boss is going to get dinged at government inspection time and possibly fined if you mess up.  So protect your job and fill out the MARS.

 

Principle No. 3: The MARS makes caregiving easier.

    A properly filled out and reviewed MARS makes caregiving easier. This happens because of better communication, uniform caregiving, enhanced professional appearance, and better therapy outcomes.

 

Better communication and uniform caregiving

     Keeping your client healthy is not a simple task. It takes the efforts of an entire team of health care specialists. Doctors, dentists, pharmacists, nurses, therapists, case workers, care providers, and family members’ efforts must be combined and coordinated around all the twists and turns of the client’s health outcomes. Every member of the team must be able to communicate effectively way with each other. If not, there will be  a lot of extra confusion and adjustments. All of which boils down to more work for you, the primary caregiver. 

     I’ve seen it happen. Patient A goes to doctor B for one complaint. Then they go to doctor B with another complaint, but don’t tell doctor A. Doctor B sends the patient to therapist C. Visiting nurse D shows up to help and reports back to doctor A but not doctor B. A Family member sees a commercial for product E and buys it for the patient. On and on it goes until the patient has totally forgotten what they are doing for their health.  Fifteen drugs later, the patient is in a real mess despite all the sincere efforts of the caregivers involved.

    Or maybe you’ve experienced the following. Caregiver A gives the meds in a certain way, then goes for her days off. Caregiver B gets new instructions from the doctor, which temporarily changes the way the meds are given so that they can safely perform an upcoming procedure. Caregiver B forgets to tell caregiver A the new instructions, so when caregiver A comes back to work, it’s business as usual. When it’s time for the procedure, the patient is unprepared and everyone has to start all over, or worse the patient gets harmed.  The above is a perfect example of “If it wasn’t written down, it didn’t happen.”  It’s also a good example of why an incomplete MARS can get you sued.

    A properly filled out and maintained MARS cuts through all that confusion. Everyone knows what’s going on, and is up to date with all the therapies involved. There is no duplication or wasted effort, making caregiving easier.

 

It makes you look professional

     Let’s face facts. Everyone assumes that in-home caregivers are the bottom of the totem pole. They assume that the only reason you’re in health care is because you couldn’t find anything else to do. Don’t you hate it when you’re treated like a teenage babysitter? That prevailing attitude is unpleasant to work under, and it takes a lot of extra work to overcome. Besides, no one likes to be thought of as stupid simpleton.

     It’s very gratifying to see the change in attitude when a condescending heath professional, who assumed you were a country bumpkin, looks through your professionally filled out MARs.  A neat and orderly MARs earns you respect. When people listen to you, you get more cooperation and your job gets easier.  

 

Better outcomes

     A properly filled out MARs includes the PRN and incident logs. They can give vital information about the patient to medical decision makers. Trends, patterns, side effects, and worsening conditions can be detected. Filling out and paying attention to the MARS allows you to see the tip of a large iceberg of problems before you run into it. Consider the following example.

     When she looks at the MARS report, caregiver Jane notices the client Sue has been taking a lot more anxiety meds this month. Client Sue is quiet and never complains, so caregiver Jane knows something is wrong and sends her to the doctor. The doctor is able to see a manic episode coming on and is able to control it before client Sue gets out of hand. The MARs once again made taking care of a client that much easier.

 

Principle No. 4: MARS prevents errors.

     Modern health care is complex, pressured-filled, and constantly changing.  As a result, errors will and do occur.  To list all the ways mistakes can be made would just be depressing. To sum it up, I’ll just reference  the Institute of Medicine’s July 2006 report Preventing Medication Errors, which says medication errors harm an estimated 1.5 million Americans each year, resulting in upward of $3.5 billion in extra medical costs.  And you thought you were the only one who makes mistakes.

     If you pay attention to what is on the MARs and fill it out as you give the medication, you can catch medication errors before they get to the patient. You will catch the mistakes that others make and prevent the ones that you might make yourself.

      Never assume that strange orders or different-looking pills are just a change from the doctor that you didn’t know about. Remember the principle, “If it’s not written, it never happened.”  When things are different and undocumented, verify them. “When in doubt, shout it out,” will keep your clients safe from  potential harm of medication errors.

 

Diversions

     Another mistake that the MARs can prevent is an error in judgment - an unwise decision by either the patient, family member, or caregiver to steal a client’s medication. Diverting a client’s medication for personal use is illegal and immoral. It harms the abuser and the patient who needs the medication.

    Drug diversion needs to be stopped. The best way I know of is to keep track of the number of drugs that are supposed to be on hand. With some calculations, the MARS can tell you how many pills are supposed to be left at any given time. Sometimes the drugs will be taken and charted as if the patient took the drug. The PRN log can be verified with the patient to see if they actually got the medication. If the patient is complaining of unresolved health issues, double check the PRN logs to see if the patient is getting the meds that have been charted.

 

For those in charge

      A messy, gap-filled MARs sends up a big red warning flag that should send you running to count those pills and account for every single one.

     It would be well worth the effort of care home owners to periodically count the narcotic drugs in their home. It sends a loud message to potential thieves - I’m watching.

   When your counting doesn’t turn up any discrepancies, you might think that it’s all a wasted effort. I would have to say you’re wrong. Your efforts are succeeding. You can tell because there are no discrepancies. 

 

The Basics of Filling Out a MARS?

  • Who’s responsible for filling out a MARS? Simply: everyone. If you do the action, then it’s your job to record it. Write in your initials when you chart and record your full name by your initials on the signature log.
  • When do you fill out the MARS? Right after you give the medication. Never before. That causes errors. Never later, trying to catch up all at once. That’s just plain sloppy and lazy. You’ll never get the full benefit from the MARs that way.
  • What do you fill out a MARs with? An ink pen, never anything that can be erased or smudged out. Always have a spare pen stuck right in the MARS binder just in case you misplace the first one.  
  • Where do you store the MARs binder? Any place that is easily accessible to care givers but not to the public. Privacy laws protect the personal information about your clients and needs to be protected from prying eyes. Don’t go overboard. Too much secrecy and you’ll discourage caregivers from filling it out in a timely fashion.
  • What do you do if you make a charting mistake? Never erase or use white out- ever. Just draw a line thru the error and initial it. Then leave a brief explanation if needed. The principle is that anyone should be able to read and understand what went on, even years afterwards.
  • What needs to be charted in a MARS? At the bare minimum, medication administration events, but if used properly, anything the doctor wants to keep track of. That includes PRN logs, medication refusals, adverse effects, patient vitals, and  patient is absence (vacations, overnighters, family visits, etc.). You have to be a bit flexible here. Some government officials might want some client details charted elsewhere. You can’t blame them. If you had the go through as many MARS as they do, you would want it simplified too. For such limitations, consult with the government inspector.
  • How much details do you have to chart? Chart facts, not opinions, and be brief. It’s OK to write the same thing over and over. This is not great literature, it’s a MARs.  Headache resolved written 11 times in a PRN log is perfectly OK if it tells what needs to be said. But keep a couple of blank pages in the MARS binder just in case a longer explanation is needed. Then place the proper reference so the paper trail can be followed. Example- therapy failed, see progress notes page 2.
  • What are the Five R’s? You might have heard about the Five R’s. It’s a simple method to prevent errors. When giving meds and charting, always be sure it’s the 1. Right person, 2. Right drug, 3. Right dose, 4.Right time, 5. Right route. If you are frazzled or tired, double check yourself by going through the Five R’s backwards. I would paste the Five R’s right inside the MARs Binders.

 

Charting in the MARS

     Recording information in the MARS is more than just simple recordkeeping. It is a living document that grows and can be used for several different purposes by multiple people.  Here are a few important details to remember:

  • A check mark means nothing. Always use initials.
  • Never chart for another employee.
  • Never leave blank spaces. Account for every space. Example- POH- patient out of home. At the very least, put a line through each space.
  • Keep it up to date. Record changes right away. Then make sure whoever  prints out the fresh MARS get the changes as well.
  • Always review the new MARS when it come out. You’ll catch more mistakes if you assume it’s wrong until the MARS is proven accurate.
  • Review the MARS for changes at the start of every shift.
  • This is legal document. Spelling and handwriting neatness count.
  • Do not record a personal opinion unless it’s noted as such.
  • Don’t forget to chart the additional info required for PRN  medications.

 

Miscellaneous

The following are a few miscellaneous items that don’t quite fit anywhere else.

 

Abb.- abbreviations

     There is not a lot of room on a MARS so abbreviations are OK as long as you use generally accepted ones. If you make up your own, then you’ll have to put in an abbreviations key in the chart notes. Here is a list of common abbreviations;

PO- by mouth

PR- by rectum

PC- after meal

AC -before meal

QAM - in the morning

QHS - at bedtime

QD- every day

Bid- twice daily

TID- three times a day

QID- four times daily

Q4h- every 4 hours

QH - every hour

Ad lib- as desired

PRN - as needed

Gtts- drops                 

H/A- head ache

BP- blood pressure

Abd- abdomen

AD- right ear

AS- left ear

AU- both ears

SOA- swelling of ankles

ADR -adverse drug reaction

ADLs- activities of daily living

APP- as per protocol

Aq- water

BG- blood glucose

Bld- blood

BM- bowel movement

B/O - because of

Sx- symptoms

Tx- treatment, therapy

Rx- prescription, drug

WF- with food

D/C discontinue

Hx - History

SOB -shortness of breath

MDI- meter dose inhaler, inhaler

HCF- health care facility

N/V- nausea and vomiting

NKA -no known allergies

n/t- numbness and tingling

Supp- suppository

LBP- low back pain

DZ- disease

OU- both eyes

OD- right eye

OS- left eye

Pt- patient

R/t- related to

RXN- reaction

SE- side effect

Sl- under the tongue

UD- as directed

UOP- urinary output

Unk- unknown

Ung- ointment

For a more complete list consult http://en.wikipedia.org/wiki/List_of_medical_abbreviations

 

Dispensing Medication

     Dispensing medication is a routine task that can lull you into a false sense of security. Even though it can get monotonous, you should remember that you can cause harm with every single dose given incorrectly.   Here’s a list of good  medication-dispensing techniques.

  • Double check the Five R’s.
  • Never leave the medication in front of the residents.
  • Watch the patients take the medication. Verify it’s taken when in doubt.
  • Chart immediately afterward.  
  • If it doesn’t look right, assume it’s wrong.
  • Listen to the input from the patient and the family. (Example: I have never taken that medication before.)
  • Never use a middle man to hand out the meds.             

Use the Info in the MARS

     Actually use the information recorded in the MARS. Get the full benefit from the effort. 

  • Follow up and communicate all ineffective PRN medications. Consider each episode as the tip of a larger iceberg of trouble.
  • Pay attention to the frequency of the PRN meds. It’s an important clue to how the underling condition is changing.
  • Copy important observations and send them to the doctor or other medical practitioner.
  • Watch for side effects.
  • Find out why resident refuses medication.
  • Suspect inappropriate caregiving when the MARS is sloppily filled out. You know the state inspector is going to.
  • A neat MARS equals an easier inspection, which leads to a happier inspector.

 

The right to refuse and what to do about it

     Every client has the right to refuse a medication regardless of the consequences. Even though no medication was given, it is still a significant event and has to be charted in the MARS and followed up on. Each facility has its own procedures on how to chart a refusal. If you don’t have one, I suggest the following.

1.      Find out why they are refusing and address any underling problem, then offer the med again.

2.    If they refuse again, put off that particular medication until last. Then offer it again.

3.    If they refuse the third time, then chart it with refused or a capital R making special note what R means on the signature log. Then chart the reason for the refusal.

4.    Notify the facility manager and the manager will notify the prescriber. (The prescriber won’t want to be bothered unless it is significant or a pattern starts to develop.) 

     Refusals are important clues about drug therapies. Asking the why questions can reveal problems with side effects, lack of patient understanding and the appearance of significant changes in patient health. Once you have determined the true reason why the patient refuses, chart it if they continue to refuse.    

    You will have fewer refusals if you give the patient a choice other than yes and no. The second time the drug is offered, give them a choice on how to take it. Instead of saying, “Do you want your meds now?” say “Do you want to take it with water or juice.” Or, “Do you want me to put it in applesauce, pudding, or cheese sauce?”  

Caregiver notes-

     I recently asked a state inspector what gets dinged the most in their inspections of the MARS. He said the three most common deficiencies are:

1.      Physician’s orders are not copied to the MARs exactly. I know it’s most likely the pharmacies fault, but you are the one getting dinged. Take time to review each new MARs that you get. Then make sure that it is exactly the same as your doctor’s orders. It’s OK to ask the pharmacy to change the MARs and send you a new one.

2.    Other doctor orders are sometimes forgotten. Like using diabetes test strips or treatments. If the doctor writes the order, you have to chart it.

3.    Pharmacies keep track of drug allergies. You have to keep track of all allergies. The common one that is forgotten is hay-fever or seasonal allergies. If the resident gets allergy medicine,  the inspector is going to look for which allergies are listed.

     Work with the pharmacy and the doctor’s office to make everything match up. Sometimes the easiest is for you to write up a note and send it to the doctor for a rubber stamp approval.

Example. The doctor writes give 100mg ibuprofen twice daily. The pharmacy sends you ibu 200mg give one- half twice daily. It’s the same thing, but you’re going to get dinged for it. Just send a note off to the doctor saying ibu 200mg give ½ twice daily-  yes ___ no ____? 

 

Conclusion

     Caregivers may not be used to charting in a MARS. It does require a new way of thinking about caregiving and medication administration. Once the caregiver gets used to the task, they will find that filling out the MARS can benefit them in many ways. The MARS can be a source of important information about the client and their changing health. It can help protect against medication errors. It will coordinate care efforts and increase cooperation between caregivers and other medical practitioners.   When done properly, the MARs improves the overall quality of health care in the home.

 

As always, good luck in your caregiving efforts.

Mark Parkinson, RPH

   

References:

1. Provider Manual For Medication Administration by Unlicensed Personnel, RN Orientation Curriculum, Book 1. West Virginia Department of Health and Human Resource . rev1/14/13

http://www.wvdhhr.org/ohflac/amap/resources/amap_rn_curriculum_book_1.pdf

2. Medical Orders and Medication Administration Record (MAR). Ensuring Quality Care, chapter 11 Medication Administration.  Oregon Department of Human Service. SDS 0341.Rev 12/02.

http://www.oregon.gov/dhs/apd-dd-training/EQC%20Training%20Documents/Medical%20Orders%20and%20Medication%20Adminstration%20Record.pdf

3. Medication Administration Course, Training Program, Presenter’s Guide. Illinois Department of Human Service. 02/01/11

http://www.dhs.state.il.us/onenetlibrary/27896/documents/by_division/division%20of%20dd/medicationadministration/section5presentersguide.pdf

4. Key Facts About Patient Safety. National Patient Safety Foundation

http://www.npsf.org/for-patients-consumers/patients-and-consumers-key-facts-about-patient-safety/

5. Medical Abbreviations. Wikipedia The Free Encyclopedia

http://en.wikipedia.org/wiki/List_of_medical_abbreviations

 

Caregivers Are from Venus but Medical Administration Records Are from MARS

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