Computer Generated Medication Administration Record

cMAR Self Learning Package

Initial printing 2014: Authors D. Elsayed. A. Eichler. D. Johnston. Reviewed January 2015

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Contents

OBJECTIVES......................................................................................................................................................3

INTRODUCTION ...............................................................................................................................................3

DEFINITION ......................................................................................................................................................3

GENERAL GUIDELINES .....................................................................................................................................3

TRANSCRIPTION EXPECTATIONS .....................................................................................................................4

HOSPITAL-WIDE MEDICATION RELATED POLICIES ..........................................................................................5

TRANSCRIBING NEWMEDICATION ORDERS ...................................................................................................6

SPECIFIC REQUIREMENTS ..............................................................................................................................10

IV Orders ..........................................................................................................................................10

Saline Locks and CVADs ....................................................................................................................10

Decreasing Doses of Medications ....................................................................................................10

Diabetic Medications........................................................................................................................11

Anticoagulants..................................................................................................................................11

TPN ...................................................................................................................................................11

PCA, Epidural, and CADD Pump Orders............................................................................................12

“Hold” and “Suggest” Orders ...........................................................................................................12

Automatic Stop Date………………………………………………………………………………………………………………….13

Even / Odd Day Dosing .....................................................................................................................12

Autosubstitution Orders...................................................................................................................12

Medical Directives ............................................................................................................................13

PRINTING PROCESS........................................................................................................................................14

cMAR for all patients on the unit……………………………………………………………………………………………...15

cMAR for specific patient on the unit…………………………………………….……………….………………………...16

Blank patient specific scheduled and prn medication cMAR……………………….…………………………….17

MEDITECH DOWNTIME .................................................................................................................................18

24 HOUR CHART CHECK.................................................................................................................................12

VERIFICATION PROCESS.................................................................................................................................19

DISCREPENCY IN ORDERS ..............................................................................................................................19

REFERENCES……………………………………………………………………………………………………………………………………………21

cMAR QUIZ ....................................................................................................................................................22

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OBJECTIVES

1. 2.

3.

INTRODUCTION

The cMAR is the legal record of medication administration. All medications administered at RVHS are prepared and dispensed from the entries on the cMAR. Accurate transcription of orders is an important part of the continuity in the care of all patients. Completion of the Order Transcription Self Learning Package is a prerequisite for competency achievement in utilization of the cMAR.

cMAR: computer generated document that serves as a legal record of the drugs administered to a patient during their hospital stay. Each cMAR includes: Demographic section, type of cMAR (Scheduled or PRN Medication Administration Record), and medication entries section.

- -

Best Possible Medication History (BPMH): A complete and accurate list of current home medications that serves as a list of medication orders when reconciled by the ordering practitioner. Medication Treatment and Review Form (Form #1122): A printed list of all current hospital medications that is used as part of the medication reconciliation process at time of patient transfer from one level of care to another.

- - - - -

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EXPECTATIONS

TRANSCRIPTION

1. Orders are processed in an accurate and timely fashion:

1) Stat 2) Urgent or ASAP 3) Routine Orders ** This means that all orders should be received by pharmacy (either by fax or being sent

down) well before pharmacy closes each day to ensure all orders can be entered by a pharmacist in a timely fashion. All orders transcribed by a Unit Clerk must be verified and co- signed by a nurse before they are carried out.

** THIS MEANS TWO SIGNATURES ON EACH MEDICATION IS NEEDED BEFORE ANY MEDICATION CAN BE GIVEN.

E.g.: a clerk transcribes and a nurse verifies, a nurse transcribes and another nurse verifies, or pharmacist enters the order and a nurse verifies at top of cMAR (each process resulting in two checks towards each medication).

2. Any ambiguity surrounding an order must be clarified with the ordering practitioner by the

nurse or pharmacist.

3. All medication orders will be processed in a timely manner, ensuring that the patient receives the medication at the earliest possible time.

4. All medication orders and re-orders are written on Practitioner Orders Form and contain all of

the following information:

5. Transcription is completed using the appropriate cMAR. Ensure ALL cMARs include patient’s demographics, allergy status, and all components of the medication order using only RVHS approved abbreviations.

6. Unless otherwise written by the prescriber, stop dates are in effect.

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7. When transcribing new scheduled medication orders and administering the first dose, the nurse must follow the First Dose Phase in Chart as per Policy M-26 unless otherwise written by the Prescriber.

HOSPITAL-WIDE MEDICATION-RELATED POLICIES

Medication Orders

M-5

Approved Abbreviations Currently Replaced by HE-ADMIN-0800

M-10/HE-ADMIN-0800

Urgency of Medication

M-20

Dangerous Abbreviations Currently Replaced by HE-ADMIN-0800

M-15/HE-ADMIN-0800

Automatic Stop Dates

M-30

Automatic Therapeutic Substitutions

M-35

Verbal Orders and Telephone Orders

M-40

Medication Administration Documentation

M-90

Transcription, Preparation, Administration and Documentation of Medication

M-120

Medication Reviews

M-135

Double checking high alert drugs

M-170

RVHS Standardized Medication Times

M-25

RVHS First Dose Phase-In Chart

M-26

Hold Orders

M-a-45

“Hold” and Reassess orders

M-45

Even/Odd Day Dosing

M-c-50

Short-acting Insulin Sliding Scale Protocol

M-c-100

Unit clerk education and order transcription

ADMIN PP-130

Verification of doctor’s orders

V-2

Computerized Medication Administration Record

ADMINPP-320

Meditech Downtime cMAR Module

ADMINPP-330

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The Process of Transcribing New Medication Orders

New Admissions / New Orders

When patients are first admitted, or when new orders are written, the orders will need to be manually written on a blank cMAR or in the next blank entry section of the patient’s current cMAR. If the medications are part of an order set or protocol which has a corresponding preprinted cMAR, the cMAR template may be used. The pharmacist will enter the medications into the Pharmacy Module and they will appear on the next printing of the cMAR. If the patient is admitted after Pharmacy hours, the medication entries will need to be hand written as these orders will not appear on the next cMAR. In this case medications will be administered and documented using the handwritten entries following the process below.

1.

2.

Components of the Meditech cMAR entry

Patient name and Demographic

Date cMAR is active

Allergy List

Type of cMAR

Columns for Administration

Times

Medication Entry

Dose, Route, Frequency

Times and initial

Label Comments: Special considerations

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3.

4.

a. Drug: Name of medication.

b. –

c. Frequency: As per order (i.e.: Q4H, Q6H).

d.

e.

f. Verification spaces: both of these spaces need signatures (from the transcriber and verifier). E.g. the clerk transcribes the order and places a signature in the first area, a nurse must then verify this order as being correct and then places their signature in the nurse area.

g. Nurse: The initials of the nurse transcribing or verifying the order. Orders may be verified or transcribed by a nurse within her scope of practice

5.

(i.e. “2 7/ 11/2014 30/11/14 B.N. RN).

R/O: 27/11/2014 B.N R.N.

30/11/2014 B.N R.N.

6.

Discontinued 27/09/2014 B. Nurse R.N.

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7.

8.

If SBP greater than or equal to

9.

10.

11.

Future Date

Note: “Hold Lasix for 3 days” OR “Hold Lasix” is not an acceptable order and will require clarification and direction at the end of the HOLD period.

When transcribing a new order to place a medication on hold, write “HOLD” the date, time, and initials in INK across the right-hand time columns of that medication section for cMAR. The

medication will continue to print on the daily cMAR. “HOLD” will be indicated in the comments sections and on the right hand side.

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Suggest Orders: Orders written by Allied Health or consult physicians as “suggest” orders are not transcribed until confirmed by the attending/most responsible physician. The attending physician must be contacted regarding the suggest orders as soon as possible for approval/discontinuation of the orders. In the case of two or more doctors treating the patient, if the orders appear contradictory, the orders of the attending physician are followed until they can be clarified by the attending physician.

12.

a)

b) Linked prescription number

c)

13.

Keep with current cMAR

File and use as per unit routine

14.

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SPECIFIC REQUIREMENTS

1. IV Orders

For intravenous infusions with KCl, MVI, Ca Gluconate, or other additives, transcribe the additive on the SCHEDULED MEDICATIONS cMAR. Administration times will not be indicated. When documenting for an IV infusion on the SCHEDULED

MEDICATIONS cMAR, include the time and initial of the nurse hanging the bag.

Example Order: IV N/S with 40 mmol KCl/L @ 100 mL/H

0200

BN

RN

2. Saline Lock

In accordance with the saline lock policy, flushes are Q8H, or following medication administration or blood collection. Flushing of the saline lock is documented on the SCHEDULED MEDICATIONS cMAR. Remember to write “and after meds or blood collection” in the comments section. The routine flushing of un-accessed lumens of a central line (PICC, subclavian, jugular or femoral) can be placed on the c MAR similar to the saline lock. Central lines are flushed every 7 days and PRN when not in use with 10 mL (minimum) of normal saline. Flushing of these lines is also done prior to and after medication administration and blood collection. Positive pressure devices (PPDs) are also changed every 7 days with flushing of the central line. Ensure that the Kardex is updated with the date of the next flush/PPD change. (Refer to policy C-9).

3. Titrating Doses of Medications (i.e. decreasing doses of prednisone or Nicoderm)

When transcribing the order to a blank cMAR entry section, specify the titration directions in the comments section. For example, a prednisone order may say "reduce by 5mg per day".

When the order has been entered in Meditech, the cMAR will record and calculate the dose for each day. This will automatically print on each new cMAR. When the medication is due the time of administration will appear in the appropriate time column. Each successive decreasing dose will indicate “FUTURE START DATE” across the right hand time columns. Following administration, initial next to the ordered dose entry in the time column.

Dose due

Future

date

Example Order: Nicotine Patch 14mg/day then Nicotine Patch 7mg/day

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4. Diabetic Medications

All insulin and antidiabetic medications will appear on the SCHEDULED MEDICATION cMAR. The sliding scale will appear in the medication entry section. "see Diabetic Protocol Sheet" will be written on the right hand side of the cMAR.

As per current practice, documentation of administration and POCT results will be Recorded on the Diabetic Protocol Sheet

Sign on the diabetic Protocol Sheet

Sign on the diabetic Protocol Sheet

Sliding Scale Insulin times of administration

are noted here, but sign on the diabetic protocol

sheet

5. Anticoagulants All anticoagulant medications appear on the scheduled cMAR. The Nomogram Scale and “see Anticoagulation Dosage Record” is written manually across the right hand columns of the cMAR.

As per current practice, documentation of medication administration, hanging of

heparin IV bags and APTT/INR results are hand written on the Anticoagulant dosage record. The daily dose of Low Molecular Weight

Sign on diabetic Protocol sheet

Administration times are indicated

Sign on the anticoagulation dosage record

Sign on anticoagulation dosage record

Heparin/Coumadin is given at 1800. (Coumadin Nomogram is RVC only).

Orders for sequential compression device and TED stockings will also appear on the cMAR. Sign in the appropriate time column

6. TPN New TPN orders are manually entered into the next blank entry section on the SCHEDULED cMAR. The amino acid order and the intralipid order are treated as two separate medication orders.

Transcribe the intralipid order as:

Drug – “lipids” Dose – “%” Route – (could be central or peripheral IV) Rate – in the comments area

Transcribe the amino acid order as: Drug – “Amino acids with additives” Route – (could be central or peripheral IV) Rate – in the comments area

If the rate/volume is 2000mL/24 hrs and there are ingredients that are added daily, there will

Lipds % (10 or 20)

Route (central or peripheral IV)

Rate

MD name BN AE

Amino Acids with additives

Route (central or peripheral IV)

Rate MD name BN AE

be two different solutions and they must be differentiated as Amino acids #1 in one medication section and Amino acids #2 in a second medication section.

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START/STOP 2300-0659

28/08/14

R/O: 27/11/14 DB RN

27/11/14

30/11/14 DB RN

Once Pharmacy has entered the information into the pharmacy module, the list of additives will automatically print on the next cMAR. If the additives are different on scheduled days, for example, only added weekly), the cMAR will automatically calculate the date and it will appear on the cMAR when scheduled. Note: If the rate/volume is 2000mL/24 hrs and there are ingredients that are added daily, there will be two different solutions and they will be differentiated on the cMAR. You must verify the solution you are hanging.

7. PCA, Epidural, and CADD Pump Orders cMAR templates are available for specific order sets and protocols. If available, you may use the template for new admissions/new orders. Ensure the patient’s demographic information has been included on the cMAR. Verify each entry against the Order Set, complete any missing information and discontinue medications that were not ordered. The cMAR will need to be verified as accurate following standard procedure and each entry co-initialed.

If not using a template, medication entries will be hand written on the cMAR as per the following: Continuous infusions and single dose bolus doses are transcribed onto the SCHEDULED cMAR. Orders for PCA, PRN bolus epidural doses, medications for side effect management, and breakthrough pain management are transcribed on the PRN cMAR. Note: PCA and Epidural protocols also have a 24 hour flow sheet that is part of the required documentation. Across the right hand time columns write “see 24H flow sheet”.

9. Stop Date When a medication has a specific time frame or follows the stop date policy, the schedule time on the right hand column will appear blank if the medication is not due or expired and needs to be reassessed. In cases where the stop date is changed, the stop date is crossed off and the new stop date is transcribed immediately below the previous date and includes the reorder date and initials of the transcriber (i.e. “27/09/2014 R/O 29/09/14 RN). All medications have a minimum 90 day stop date. Other medications such as antibiotics and narcotics have a stop date specific to them.

10. Auto substitution Orders Pharmacy Medication Clarification Form (Form #616) or the Automatic Therapeutic Substitution Form (#1526) is to be placed in the doctor’s order section for physician/NP review. These forms are to be transcribed as any other order and signed off by the transcriber. The previously ordered medication is to be discontinued and the substitution medication is to be transcribed. Refer to policy M-0035. Pharmacy will input the substituted medication and it will appear on the cMAR when the next one is printed.

11. Even / Odd Day Dosing

When medications are ordered specifically for even or odd day dosages, the medications will appear on the daily cMAR even when not scheduled to be given. The cMAR will indicate the dosage due by identifying the time of administration in the right hand time column. If there is no time of administration the medication is not due to be given.

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As current practice the even/odd day dosing same dose will be given on two consecutive days when there are 29 or 31 days in the month. Physicians should correct the order to be written so the computer recognizes it, such as give every other day, or give Q2Days.

12. Medical Directives

When implementing orders from a Medical Directive (e.g. Acetaminophen) write the order on the Practitioner’s Order Sheet as “name of medication dose, route, and time as per medical directive #…” The medication is then transcribed in the usual manner in the next blank entry space on the SCHEDULED cMAR Section.

13. Nitroglycerine Patches

If a nitroglycerine patch is ordered with administration times as well as removal times write in “on” and “off” onto the cMAR to prompt the nurse to remove the patch at the appropriate time.

14. Use of Highlighting

Highlighters may be used to highlight any information on a cMAR that a staff feels would help in making medication administration safer. Some ideas for highlighting may include: highlighting the type of cMAR, the dosages of medications, comments etc.

15.

IT IS VERY IMPORTANT WHEN LOOKING AT CMAR THAT YOU ARE LOOKING AT THE DOSAGE TO BE GIVEN NOT THE CONCENTRATION. At the top of the medication you will see the medication as supplied by pharmacy; however this may not always be the correct dosage to give. ENSURE YOU ARE ALWAYS LOOKING AT THE DOSAGE AREA OF THE CMAR BEFORE ADMINISTERING MEDICATION TO ENSURE CORRECT MEDICATION ADMINSITRATION. Example: Seroquel 25mg tab supplied, however dosage is 12.5mg. You would have to give half the tab (not the full tab that pharmacy supplied). See comments on cMAR for additional medication information.

PRINTING PROCESS

FOR UNITS USING THE 7 DAY CMAR, OR A COMBINATION OF BOTH A 7 DAY CMAR AND A 1 DAY CMAR – REFER TO SUPPLEMENTAL FOR FURHTER INSTRUCTION.

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The cMAR will automatically print on the unit at a predetermined time. However, there will be times when the cMAR will need to be printed before this time.

1. BLANK cMARs will need to be printed for new admissions or new orders when blank entry spaces are not available.

2. In some circumstances the cMAR for new admissions may be printed early on the unit once pharmacy has completed entering all medication for the newly admitted patient. This can prevent the nursing staff from transcribing many medication orders. This depends on time of day and pharmacy resources.

To Manually Print the cMAR:– Print Routines menu

Connect to the Meditech system and select 1 for Live

Enter ID and Password

cMAR PRINT ROUTINES

screen

Choose 300

In the cMAR PRINT ROUTINES menu item 300 will allow printing of the cMAR that includes all the medications that have been entered into the Meditech system by Pharmacy. This is the document that prints automatically at 2200 on the unit. Once 300 is selected, a pop-up window appears:

Press enter

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How to print the cMar for all patients on the unit: – Print MARs options

Enter Order Entry in Meditech to screen

Unit location F9 Look-up ‘Name’ and ‘Printer’ will

auto populate

INP for inpatient units

Verify date.

“T” for MARS that will be active from 2300 onwards to

2259

Scroll and select

RVC.MAR 1 RVC MAR – 1 Day

Select MAR

Format press F9

Continue to Press enter until

? “Queue to print?” screen appears.

Review: Steps to manually print all patient’s cMAR on unit

Note: the cMARS will automatically print on the unit at a specified time. If needed a manual print run can be initiated by following these steps

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rs.

1.

2.

3. - 4. -

-

5. – 6.

How to print the cMar for one patient on the unit: – Print MARs options

Enter Order Entry in Meditech to screen

**Complete the bottom portion of the screen only

INP for inpatient units

Select Patient

F9 Look-up

Top section to remain blank – or all patient’s cMARs will print

Status, Age/Sex, Location, Printer information will auto populate

Verify date.

“T” for MARS that will be active from

2300 onwards to 2259

Scroll and then select

RVC.MAR 1 RVC MAR – 1 Day

Select MAR Format press

F9

Continue to Press enter until

? “Queue to print?” screen appea

.

Review: Steps to manually print one patient’s cMAR on unit

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rs.

Note: the cMARS will automatically print on the unit at a predetermined time. If needed a manual print can be initiated by following these steps. Remember: only complete the bottom portion of the screen if you are printing the cMAR for one specific patient

1.

2.

3. -

4. - -

5. – 6.

7.

How to print BLANK SCHEDULED MEDICATION or BLANK PRN MEDICATION cMar for one patient on the unit: – Print MARs options

This process is the same as for manually printing the cMAR for one patient on the unit except when entering the selection in the Alternate MAR format box scroll and choose BLANK PRN MEDICATION CMAR or SCHEDULED MEDICATION CMAR.

Enter Order Entry in Meditech to:

**Complete the bottom portion of the screen only

Select

Patient F9 Look-up

Verify date.

“T” for MARS that will be active from

2300 onwards to 2259

INP for inpatient units

Top section to remain blank – or all patient’s cMARs will print

Scroll and then select

Status, Age/Sex, Location, Printer information will auto populate

Select MAR Format press

F9

Continue to Press enter until

? “Queue to print?” screen appea

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NTIME

Review: Steps to manually print one patient’s BLANK PRN or SCHEDULED MEDICATION CMAR

Note: medication orders received outside of pharmacy support hours will be transcribed manually on to blank cMARs that contain the patient’s demographic information from the Print Routines menu in Meditech. Remember: only complete the bottom portion of the screen if you are printing the cMAR for one specific patient

1.

2.

3. -

4. - -

5.

6.

7.

MEDITECH DOW

Planned Downtime: This is a scheduled time that Meditech is unavailable due to planned maintenance or upgrades. Users are notified in advance of the date, time and expected duration. The unit clerk/ Nurse shall

1. Ensure blank cMARs are available for medication documentation for each patient. This may be either sufficient blank entry spaces on current cMARs or BLANK SCHEDULED MEDICATIONS or BLANK PRN

MEDICATIONS for each patient. 2. Ensure Meditech downtime blank cMARs are available for new admissions. Patient demographics

may be added with the patient’s sticker top left hand corner. 3. Communicate to pharmacy all new orders prior to downtime. 4. Review all new medication orders and manually transcribe the medications on to the downtime

blank cMAR according to the process outlined in the cMAR Policy ADMIN-PP-320 and the Self- Learning Package

Unplanned Downtime: This is an unscheduled interruption in Meditech service that occurs without advanced warning. The unit clerk/ Nurse shall

1. Ensure Meditech downtime blank cMARs are available for new admissions and new orders. Patient demographics may be added with the patient’s sticker top left hand corner.

2. The medication orders written during the downtime will be entered into the Meditech system as soon as possible once Meditech is available. Pharmacy shall ensure the date is adjusted to the date of the order.

3. The unit clerk and or Nurse will ensure that all new orders are communicated to pharmacy as per unit specific protocol.

4. The medication orders will be manually transcribed according to the cMAR Policy ADMIN-PP-320 and the Self-Learning Package

** For Meditech down time procedure refer to Meditech Downtime Procedure Policy. ADMIN-PP 330

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Return to Live Meditech: Once Meditech is available

1. The unit clerk or nurse shall communicate to pharmacy any new medication orders that occurred during downtime

2. Pharmacy will enter new medication orders as soon as possible. 3. Once pharmacy has updated the medication profile and the system is able to generate the

updated cMAR, the cMAR will print at the usual time.

12 HOUR CHECK

The night nurse is responsible for checking that all orders for the past 12 hours have been transcribed appropriately and are signed off on the Ordering Practitioner Form. If any orders are not initialed or not signed off at the bottom of each set of orders, the nurse is required to complete the transcription process. The nurse performing the chart check will stamp below the most recent orders “12 hour chart check” and sign with the date and time, verifying that the process has been completed.

VERIFICATION PROCESS

Newly printed cMARs must be checked for accuracy before medications are dispensed or administered from the entries using the following process:

1.

2.

a.

b. c.

- -

3.

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4.

** Remember: Medications are prepared and administered only from entries that have been reviewed and verified as accurate. **

DISCREPANCY IN ORDERS ON THE cMAR

If the nurse finds a discrepancy between the medication order and the printed cMAR he/she is to notify pharmacy of the discrepancy by completing the cMAR COMMUNICATION FORM. Once completed the form is to be faxed to pharmacy along with the original Ordering Practitioner Form so that the correction can be entered into Meditech

References

College of Nurse of Ontario (2008) Medication, Revised. Retrieved on August 16, 2010 from:

http://www.cno.org/docs/prac/41007_Medication.pdf

Edmunds, M.W. (2000). Introduction to Clinical Pharmacology . Mosby: Toronto

Harwood, J. and Lumsden, J. Transcription of Physician Orders. Toronto East General Hospital. October 2001.

Robinson, J. Medication Administration 2002. Durham College NUR2512-NRC Nursing Program.

Rouge Valley Health System Medication Policies

Rybenko,L. RVHS-CHC Transcription of Physician Orders. June 1996. Revised April 2000 by Lim,

C.

Lakeridge Health Oshawa cMAR Pharmacy Module 2014

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