Why are care inspectors obsessed with MAR charts?

What is the meaning of ‘MAR chart’?

A MAR chart is a Medication or Medicine Administration Record Chart. What a MAR chart means in practice is covered in more detail below.

What is a MAR chart?

A MAR chart is a printed or electronic chart used by workers in health and social care, for example in domiciliary care, to record medicines given and/or taken by a person, and those instances where a medicine that was supposed to be given was missed, skipped, refused and so on.

The MAR chart lets everyone involved with that person’s care know what medicines have been taken and when, along with necessary information to give or assist with medicines being taken safely.

The MAR chart will be supplied (either printed or in electronic format) with information including which medicines are to be given, at what time, at what dose and any other information that is relevant such as if they should be taken with or without food.

MAR chart for domiciliary care

MAR charts in domiciliary care or community care may sometimes be supplied pre-printed by community pharmacies or produced by the care provider with assistance from a pharmacy. Regardless of how it is produced, NICE guidance (Guideline NG67, Point 1.5.5) recommends that a MAR chart for domiciliary care should include:

• The name and date of birth of the person being cared for
• The name, strength and formulation of the medicine/s
• How often or the time the medicine should be taken
• How the medicine is taken or used (route of administration)
• The name of the person’s GP practice
• Any stop or review date
• Known drug allergies

A MAR chart for domiciliary care will often include the details of the supplying pharmacy too, the person’s GP and other relevant details. Once a MAR chart is in used it is a confidential document and should be treated with the same discretion and security as an individual’s care plan.

Often in domiciliary care MAR charts, a reason code will be used to record when a medicine was not given, e.g. 'R' for medicine was refused. If a scheduled medicine is not given for any reason, this should be recorded in the MAR chart and should not be left blank. 

Gaps mean uncertainty; the next carer to visit can't know if a gap means a medicine was not given, or the previous carer gave the medicine but forgot to complete the MAR chart. As we shall see this can lead to mistakes and potentially serious consequences. 

Why are CQC inspectors obsessed with MAR charts?

The CQC identifies “inaccurate, missed, gaps in, or inconsistent medication reporting” as a definite reason to take action and in some cases place care providers in special measures, as many have found out the hard way.

Maintaining accurate and legible medication records can be a dicey game when carers are left to scribble down notes and cram information into small boxes on paper MAR charts.

Similarly, ensuring that every carer sticks to a standardised, consistent way of recording what medication has been given – assuming that one has been put in place by management – is near impossible to enforce 100% of the time.

An even greater worry is that a carer forgets to write any of the necessary information into the MAR chart, or forgets to sign it or even worse forgets to write down anything at all!

The inspector's perspective

Why do the CQC, Care Inspectorate and Clinical Commissioning Groups place so much importance on medication records being accurate, legible and consistent? The answer is simple: safety.

For example, take this excerpt from a CQC report into a provider placed into special measures:

“The agency did not keep accurate or update Medicines Administration Records (MAR). Inspectors found numerous examples of people who were not getting their medication either on time or not following prescribing instructions. Care records were incomplete or had not been completed. It was often difficult to establish whether a person had actually received their medication. Overall, the situation with the administration and record keeping was very unsatisfactory and not acceptable.”

If anybody cannot read or understand what medication someone has been given, of what dosage and when, then they run the risk of mistakenly giving that person more medication, risking overdose.

On the other hand, the carer - seeing the gap in the MAR chart - might err on the side of caution and not give any more medication, creating the possibility that twice in a row a service user is not getting the important medication that they have been prescribed.

Additionally, when faced with gaps in MAR charts or entries they cannot read or understand, the CQC, CCSIW and Care Inspectorate have no idea if the people receiving care are getting the medication they need in the right doses.

Gaps in MAR charts let the inspectors know one thing for sure; that the care provider themselves doesn’t know which medications are being given either!

This is why as inspectorates of care quality and safety, the CQC, RQIA, Care Inspectorate Scotland and Care Inspectorate Wales, must take action against providers whose records are inaccurate, illegible, inconsistent or contain gaps.

Communication issues

Preventing gaps in communication between prescribers, a care provider’s back office and the point of care is a problem specific to domiciliary and community care services.

If for example a prescriber changes medications or dosages, then in most cases the care provider is responsible for ensuring that the MAR chart in the service user’s home is replaced or updated.

Doing so creates a hefty burden of admin work, travel time and fuel costs which all adds up month on month and when a business looks at its books at the end of the year.

If however, an up to date version of the MAR chart is not available to carers when they arrive at a person’s home they are not going to give that person the correct medication at the correct dosage.

eMAR 

This cocktail of risks and costs are pushing more and more care providers to stop relying on paper MAR charts and use Electronic Medication Administration Records (eMAR) instead.

Skills for Care’s recent ‘Good to Outstanding Care Guide’ highlighted eMAR as a practical example of best practice medications management, to help secure a good to outstanding rating:

“People’s medicine administration records (MARs) were now documented electronically on the providers’ electronic care records system. Care workers have instant access to information about people’s medicines and kept informed of any changes, such as commencing antibiotics. The system reduces the risk of errors by providing up to date information.”

the case for eMAR

eMAR links up medication administration to MAR charts directly, so that when a carer gives medication all the relevant information- including any notes – are added to that persons MAR chart automatically, meaning no gaps in medication records.

Because eMAR is electronic it uses a standardised format so that records are always consistent. With digital text there is no more scruffy handwriting to decipher, meaning MAR charts are always legible.

It goes further though. Rather than relying on paper MAR charts, carers can use a mobile app to see which medication to give of which dosage in each visit and see which medications were or were not given in previous visits.

Carers also use their mobile app to record the medications they have given or not given, add reason codes and any notes. All of this is added immediately to the eMAR chart which is visible in the back office. If any medication are missed then alerts are raised to the appropriate members of staff to investigate.  

Access Care Planning software has an inbuilt, integrated, domiciliary care eMAR system refined over years of use by domiciliary care providers, enabling services to provide safer care, reduce medication related incidents and stress for care workers, managers family members and service users.

Find out more with this eMAR factsheet.