Introduction: The Importance of Accurate Medication Administration Records

One of the biggest challenges care organisations face is ensuring that they have accurate Medication Administration Records (MARs) and that their nurses and care staff complete them correctly. I recently had the pleasure of meeting a gentleman from the Care Quality Commission, who told me that medication issues, particularly record-keeping, remain the greatest area of concern during inspection visits. So, what are the issues, and how can we get it right?

What Information Should Be on a MAR?

Guidance states that a MAR should contain the following information:

  • The name and address of the service user
  • A start date, so it’s clear which record is current or for reference if there’s a need to look back at a certain date
  • The medication details, including the name, strength, form, clear dosage instructions, and times of day. The phrase “contents of box” or using terms like “nomad” or “dosette” etc., is not acceptable.
  • If you use codes for administration, the key for those codes needs to be clearly stated on the MAR.
  • A space for the nurse or carer to either sign or initial. If initials are used, there needs to be a master record kept in the office that links initials to the corresponding carer or nurse.

Any other information on the MAR is not strictly necessary but may make the MAR more robust when in use. For example, including quantities received and returned, GP details, etc., could be helpful.

Who is Responsible for Providing the Medication Administration Records and Entering the Information?

Legally, it is the responsibility of the care organisation to provide the MAR and to enter the information on it. Many care homes receive MARs from their pharmacy as a complimentary service, but pharmacies have no legal or contractual obligation to provide MARs.

There is no official template or recommended format for a MAR, so various types are used. As long as they meet the requirements mentioned above and are completed correctly, the format that works best for your organisation can be used. The medication information for each client should be entered by the care company. Any changes to medication should also be made by the care company, written legibly in ink. If the medication has changed, draw a line through the old entry, re-write the new details on a new line of the MAR, and ideally have it checked by another person. This entry should be signed, dated, and a note made indicating on whose authority the change was made.

Codes for Administration

There are no official codes for administration or guidance on what they should be, so it is up to the care organisation to decide what information the nurse or carer should record. Good practice would be to have codes for situations such as administered, reminded, observed, not taken, refused, dose measured, on leave, in hospital, etc.

Record Keeping at the Time of Administration

Training in how to complete MARs is essential if you are to ensure that your teams do it correctly at all times. A system should be in place to identify where mistakes are being made or records are not being completed properly, so that the carer or nurse can be spoken to, given additional guidance and training, and standards can be enforced.

At the time of administration, team members must sign or initial the MAR in the appropriate space and indicate how they supported the service user. This may be done using a code as discussed above. If the person did not require medication, the carer or nurse should still sign and add a code to explain that the client didn’t require it. Please do not leave records blank, as gaps create questions and uncertainty about what happened at that time.

If a controlled drug was administered by two people, both should sign. If it was a variable dose, for example, “give 10ml or 20ml,” the exact dose given should be recorded. If a dose is refused by the service user, record that it was refused and why. Any over-the-counter or homely remedies administered should also be detailed on the MAR.

Conclusion: Seeking Further Information and Training

For more detailed guidance and hands-on training, we recommend booking our Safe Use of Medications Training Course. Equip your team with the skills and knowledge needed to ensure the highest standards of medication management in your care organisation. Contact us today at or call 0330 100 2821 to discover how we can help your organisation. You can also view the NHS MAR-chart here.