Doctors in the United States dispensed over 6.7 billion prescriptions in 2022. With so many medications prescribed annually, monitoring each patient’s treatment requires comprehensive medication administration records (MARs).
However, getting ahold of medication records for care coordination can be challenging due to data silos and other logistical obstacles. It can take providers days or even weeks to access critical MAR data when needed.
These problems contribute to the 7,000 to 9,000 individuals who lose their lives annually due to missing or incorrect medication.
Keep your patients safe by getting the medical records you need without delays. At ChartRequest, our easy-to-use Release of Information (ROI) platform paves the way for HIPAA-compliant record retrieval.
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What Are Medication Administration Records?
Medication administration records are reports that track the unique drug codes and medication a physician prescribes to a patient. This detailed record helps nurses and doctors know the following:
- Who requires the medication for treatment
- What brand and dose of drugs the patient should take
- When and how often the patient should take the medication
- How the patient should take the medication (orally, intravascularly, etc.)
The MAR is vital for ensuring patients get the right medicine at the correct dose and time — significantly improving their healthcare outcomes.
According to recent studies, medication errors lead to morbidity, mortality, and economic burden on the public health sector. The cost of caring for patients with these errors surpasses $40 billion every year.
Historically, physicians recorded MARs on paper, which compromised efficiency and security. With the development of technology and the implementation of electronic health records, digital MARs are now the standard among most modern facilities. These electronic records help reduce errors and make sharing information between healthcare providers hassle-free.
Purpose of Medication Administration Record
Medication administration records serve several functions in healthcare. For one, they are a practical way of ensuring patients receive the best care with minimal risks regarding medications.
Here’s a closer look at why MARs are such an integral part of patient care:
Ensuring Accurate Medication Administration
The main goal of a MAR is to keep precise records of all medications a patient receives. This practice reduces a patient’s risk of experiencing costly and harmful medication errors.
Studies show that implementing comprehensive barcoding and electronic medication administration technology experienced a 41% reduction in non-timing medication errors.
Improving Patient Safety
Keeping a detailed list of medications, including dosages and administration times, significantly affects patient safety. This vigilance prevents overdoses and adverse drug interactions, which could be life-threatening.
According to a study, medication errors impact more than 1.5 million people in the U.S. each year.
Common problems that develop from these mistakes include:
- Delayed recovery from injuries
- Cognitive decline
- Immobility
- Sickness
- Allergic reactions
- Physical deformity
- Chronic pain
- And more
Enhancing Communication Among Healthcare Professionals
MARs allow healthcare providers to communicate effectively about a patient’s care. A detailed medication record helps providers across the healthcare industry stay informed about a patient’s current medications. This advantage is especially observable during care transitions, such as moving from a hospital to a rehabilitation center.
Supporting Medication Reconciliation
Medication reconciliation is a process that ensures accuracy across all medication records. The MAR is essential in comparing the medications a patient needs with what they currently use. This process can reveal any discrepancies and prevent medication errors.
Improving Patient Care and Monitoring
The MAR facilitates closer monitoring of the patient’s response to treatments and medication adjustments as needed. Healthcare providers can track improvements and note side effects, making necessary adjustments quickly.
Legal and Compliance Documentation
Legal battles against healthcare providers are aplenty. The MAR serves as a legal document that personal injury and medical malpractice attorneys can use to prove that doctors provided the correct care. It also facilitates compliance with health regulations and standards, including privacy laws like HIPAA.
Patients and legal guardians file approximately 85,000 lawsuits against medical professionals annually in the United States. This statistic highlights the importance of accessing a secure and accurate MAR for enhanced care coordination.
5 Components of a Medication Administration Record
Understanding the components of a MAR is fundamental for anyone involved in patient care.
Below, you can discover the breakdown of items typical in medication administration records:
1. Patient Information
- Name: The patient’s full name, including any known aliases
- Date of Birth: Important for verifying the patient’s identity and administering a suitable medication dosage
- Patient ID: A unique identifier used to track patients in the healthcare system
2. Medication Details
- Medication Name: The specific name of the medication administered
- Strength: The medication’s potency — typically measured in milligrams or units
- Form: Forms refer to whether the doctor administers medication via a pill, liquid, injection, etc.
3. Dosage Instructions
Dosage instructions inform the doctor and patient about how much medication the patient must take.
4. Administration Times
Administration times indicate when the patient should take the medication. Some drugs may require patients to take their medicines during specific times of the day or in intervals like “every six hours.”
5. Notations for Any Adverse Reactions
Physicians note any adverse reactions the patient experiences from administered medication on the MAR. This documentation helps doctors manage and adjust the treatment to avoid future harm.
According to studies, adverse drug events (ADE) incidences range from as low as 0.15% to as high as 30%.
Medication Administration Documentation Best Practices
Best practices for medication administration records protect both patients and healthcare organizations. Here is what you should know:
Complete and Accurate Entries
Recording information with precise attention to detail matters. Physicians should list exact medication names, dosages, and routes with scrutiny. Additionally, they should review each entry for accuracy before submitting it for physical or electronic storage.
A physician should avoid blanks on the record, as doing so can lead to confusion or wrongful drug use. Doctors can either leave notes regarding omissions or verify information before proceeding.
Timely Updates
Prompt recording allows physicians to update the MAR quickly for other doctors involved in the patient’s care coordination. Digital systems that integrate real-time updates and tracking reduce the risk of errors during data migration.
Still, physicians should not over-rely on AI technology to identify discrepancies in MARs. These mistakes could lead to obstructive delays in patient treatment.
Consistent Format
Standardization means using consistent formatting for entries to avoid confusion among healthcare providers. Doctors should use clear handwriting when recording data on physical MARs and use familiar language and coding when working through electronic platforms.
Regular Reviews
Routine reviews and collaborative verification methods allow doctors to assess the quality of their MARs for future use. In the latter, more than one healthcare provider can verify critical medication entries to prevent mistakes or oversights.
Training and Education
Healthcare providers often require significant training and education to navigate the MAR successfully. While every facility deploys its own training policy, it is worth prioritizing ongoing learning during updates or security changes to the MAR policy.
Use of Technology
Digital tools allow physicians to implement MAR systems for improved accuracy and efficiency. Automation software utilizes alert modules that inform doctors of potential medication timing and dosage errors. Continue monitoring developments in healthcare technology to stay current with these advancements.
Challenges Accessing Records
Despite the critical role MAR plays in patient care, accessing these records can be a struggle for both small and large healthcare facilities.
Consider the main hurdles an employee may experience when accessing medication administration records:
Limited Availability
Organizations that continue to use paper records may experience delays when transporting or accessing MARs. Switching to electronic record management platforms can eliminate these problems.
Still, healthcare professionals may need to overcome other barriers when integrating new technology. For example, a case study by Data Ideology reveals that eliminating data silos in a healthcare-payer organization saves nearly $4 million yearly. Navigating data silos or other cybersecurity demands may take time and resources to achieve.
Data Privacy Concerns
Strict regulations protect patient information. Maintaining confidentiality can restrict authorized access to MARs, potentially slowing the process. Here are critical pieces of legislation to keep in mind when managing data:
- The Health Insurance Portability and Accountability Act (HIPAA) sets standards for safeguarding sensitive patient data. Companies handling protected health information (PHI) must implement necessary physical, network, and process security measures.
- The Health Information Technology for Economic and Clinical Health (HITECH) Act is part of the American Recovery and Reinvestment Act 2009, promoting health information technology adoption. It expands HIPAA rules for privacy and security.
- The Family Educational Rights and Privacy Act (FERPA) is primarily for educational records and applies to health records at federally funded educational institutions.
- The Genetic Information Nondiscrimination Act (GINA) prevents genetic information-based discrimination by health insurers and employers.
- The 21st Century Cures Act encourages health information sharing and emphasizes patient access to digital health data. These regulations uphold data privacy in the U.S. healthcare system, ensuring patient data confidentiality.
Technological Limitations
Some technological limitations prevent healthcare providers from viewing, transferring, or using MARs when needed. Here are a few factors to consider:
- Interoperability: Many healthcare providers use electronic health systems that cannot communicate with each other cross-platform. This problem leads to difficulties when accessing MARs between different healthcare providers.
- Technical Issues: System crashes or glitches can temporarily make MARs inaccessible, risking patient privacy.
- Cyber Attacks: Healthcare data breaches are on the rise, with healthcare being one of the most vulnerable sectors. Cybercriminals target vulnerable digital systems, making patient records inaccessible and potentially exposing sensitive information.
Ready To Enhance Medication Management?
Medication administration records are one of the best tools for combating drug-related errors during patient treatment. They contain the information physicians need to make informed decisions about care coordination and more.
Getting to these records should be easy. That is why your organization should invest in Chartrequest. Our #1 software helps healthcare professionals like you navigate record requests, tricky privacy laws, tech issues, and more.
As an electronic ROI platform provider, we make it easier and faster for you to access documents while maintaining HIPAA compliance. Our software is also easy to use to improve your daily workflow.
ChartRequest networks with over 10,000 healthcare providers, making it a breeze to build a complete medical history for patients.
If you value fast access to medication administration records, check out ChartRequest solutions. See the benefits of our software today — book a free product demo.
