Record a medication round
Where: Care → Medication round.
Who: care.health.mar.administer, the MAR feature, access to the home, and your user linked
to an active employee (see Access).
MAR = medication administration record: what was given, refused or missed.
The round window
The round shows doses due from two hours before to two hours after now, in the home's time zone.
Example: at 08:20 the round shows doses due between 06:20 and 10:20: Ruth's 08:00 Amlodipine and Metformin, Arthur's 09:00 painkiller.
Open the round
- Choose the Facility (Sunrise Elm Lodge) and select Refresh.
- Check the line Times shown in Europe/London.
- Each resident is listed with their orders and dose times. "No residents with doses in this window" means nothing is due within two hours of now.
Record a scheduled dose
| Outcome | Use it when | Reason asked | Chart code |
|---|---|---|---|
| Given | The dose was taken | No | G |
| Refused | The person declined | Yes: "Why was the dose refused?" | R |
| Withheld | Deliberately not given (GP advice, nil by mouth) | Yes | W |
| Missed | Not given, and it should have been | Yes, then an incident decision | M |
| Not available | No stock | Yes | N |
| Self administered | The person took it themselves | No | S |
| On leave | The person was away | No | L |
After saving, the slot shows the outcome, who recorded it, "· late" if recorded more than 60 minutes after its time, and the reason.
Example round, 08:20:
| Resident | Medicine | Due | Outcome |
|---|---|---|---|
| Ruth | Amlodipine 5 mg | 08:00 | Given |
| Ruth | Metformin 500 mg | 08:00 | Refused: "Felt sick; GP informed" |
| Arthur | Morphine sulfate 10 mg (controlled) | 09:00 | Given, witness Grace (see below) |
It can't be edited or deleted. If your connection drops, select Refresh and look at the slot before trying again. "This dose was already recorded as GIVEN" means it's done. Don't give it again.
Controlled drugs: the witness
- At the top of the round, choose the colleague in Witness for controlled drugs. They stay selected for the round; change them when the witness changes.
- Select Given for the controlled dose.
| Rule | Message |
|---|---|
| A witness is needed | "Choose a witness before giving a controlled drug." / "A controlled drug needs a witness" |
| It can't be you | "The witness must be a different person" |
There is no stock register in the system; keep your controlled-drug book as usual.
Residents on leave
The round notes: "On leave: record doses as 'On leave' unless the medicine went with them." Choosing Given for someone on leave asks "This resident is on leave. Record the dose as given?"
Give an as-needed (PRN) dose
The order shows "1 of 4 in 24h" and "next from 14:20".
- Check the allowance and the next permitted time.
- For a controlled drug, choose the witness first.
- Select Give PRN dose and answer "Why is Paracetamol needed now?", for example "Hip pain 6/10".
| Rule | Message |
|---|---|
| A reason is needed | "Say why the PRN dose was needed" |
| Not over the maximum in any 24 hours | "The maximum of 4 doses in 24 hours has been reached" |
| The minimum gap | "Doses must be at least 240 minutes apart" |
The 24 hours roll: they count back from now, not from midnight. Refresh first, because a colleague may just have given a dose.
Example: Ruth's Paracetamol (max 4, 240 minutes apart)
| Time | Action | Result |
|---|---|---|
| 07:00 | Give PRN | 1 of 4 |
| 09:00 | Give PRN | Refused: "at least 240 minutes apart" |
| 11:00 | Give PRN | 2 of 4 |
| 15:00, 19:00 | Give PRN | 3 of 4, then 4 of 4 |
| 23:30 | Give PRN | Refused: "maximum … reached" (until 07:00 tomorrow) |
Missed doses and the incident decision
| Button | You're asked | Result |
|---|---|---|
| Report incident | "Describe what happened (optional)" | A Medication error incident is created; follow it up in Care → Incidents |
| Dismiss | "Why is no incident needed?" (required) | No incident; the decision is kept |
It's a one-time decision. An overdue dose with nothing recorded (! on the chart) isn't a Missed dose,
so no decision is offered for it.
Late doses and daylight saving
- Late: recorded more than 60 minutes after its time. It's still valid; the chart and report show it as late.
- Clocks go forward: a dose time that doesn't exist (for example 01:30) moves forward with the clock.
- Clocks go back: a time that happens twice is used once, at the first occurrence.