Medication administration records have been widely used in residential care for many years but not so regularly in domiciliary care until quite recently. It’s great to see that they are being used much more widely now in home care and I look forward to the day where they are used in every agency I visit or train.
Why? Because they are essential to good medicines management and to provide you with evidence of medicines support or administration. They are your back up should anything be challenged. They are your way of ensuring that you meet the responsibility that you have under the law of ensuring that the 5 checks are made:-
- Right patient
- Right medicine
- Right dose
- Right route
- Right time
CQC have published a guidance document that addresses medicines administration record sheets – what information should be recorded and how they should be used. However, in practice it would appear that very few organisations are aware of this guidance and/or how to interpret it and as a result I see a wide variety of different interpretations. My concern is that the vast majority of record sheets either do not contain the required information and/or they are not being completed appropriately by the agency staff. This may be that the agency staff have not received proper training on how to use the forms, it might be that forms need to be reviewed or it might be that the agency policy is out of date or in need of review by an expert. When any of these scenarios apply – it leaves the agency wide open to litigation should an error occur that is not documented properly.
So let’s clear up some myths shall we!
It is the responsibility of the agency to provide medication administration records for their care workers to use.
The form should contain:-
- The name and address of the service user
- Date started
- Medication details including name, strength and dose of medication
- Time given/prompted/observed
- Signature of care worker
- Code for Administration or prompting or observing
It is the responsibility of the care organisation to make any changes to the record to keep it up to date at all times if a record needs to be amended
- Cross out the original direction and write the new directions on a new line
- Hand writing should be legible and in ink
- Write the name of the prescriber who authourised the changes
- Sign and date and where possible have another person witness this.
- Cross reference to daily notes
It’s worth pointing out here that the medication details must be given for each individual medicine. It is not sufficient to simply put “Contents of Nomad” or “Dosette box”. Whilst it is the responsibility of the pharmacy to ensure that the correct medication is dispensed – you are responsible for making your own checks – you cannot abdicate this responsibility and therefore you need to know that what is in the compliance aid is what is being given to the service user. Now you may not know which tablet or capsule is which – however, you should know that the names on the box match the names on the chart (which have been checked against the prescription details) and that there are the correct number of tablets or capsules there to be given.
It might also be useful to have space for the name of the GP, any allergies, and comments.
For further advice and information about medicine Administration records or if you have any questions please contact firstname.lastname@example.org