Documentation & Medication Orders

Why Documentation Matters

QMAPs are paid providers. Documentation is a legal record proving that a service was performed. State laws and regulations specifically require accurate, complete, and timely documentation for every medication administration.

The Medication Administration Record (MAR)

The MAR is the official document for recording all medication administration. Each agency may use different MAR formats, but all must capture:

• Client name (Right Person)
• Medication name — brand and/or generic (Right Drug)
• Dose and strength (Right Dose)
• Route (Right Route)
• Scheduled times (Right Time)
• Date and time of each administration
• QMAP initials or signature for every administered dose
• Notes for refusals, partial doses, or missed medications

What to Document When a Medication Is NOT Given

• Refusal: Document "refused" or "R" in the time slot, record the client's reason if given, notify supervisor
• Missed dose: Document why the dose was missed and notify supervisor
• Never leave a blank — a blank on the MAR implies you simply forgot to document, which may be treated as though the medication was not given

Medication Orders

We often call these "doctor's orders," but several licensed professionals may legally prescribe medications in Colorado, including:

• Physicians (MD, DO)
• Nurse Practitioners (NP)
• Physician Assistants (PA)
• Dentists (DDS) — within their scope
• Optometrists (OD) — within their scope

Types of Valid Orders for QMAPs

• An original or copy of a hand-written order
• A copy of an electronic/e-signature order
• A written verbal order — taken and signed by an agency RN

The 7 Parts of a Valid Medication Order

1. Client's name
2. Date of the order
3. Name of the medication (drug name)
4. Dose (how much to give)
5. Route (how to give it)
6. Frequency/schedule (when to give it)
7. Authorized prescriber's signature

Medication Timing — "On Time" Rules

There are two ways a medication time may be defined on a physician's order:

• Specified Time: The order states an exact time (e.g., "8:00 a.m."). The medication must be given at or very close to that time — your agency's policy will define the acceptable window, typically ±30 minutes.
• Time Window: The order defines a general time period (e.g., "in the morning," "at bedtime," "with meals"). The medication may be given anytime within that window — again, per your facility's policy.

In 2011, CMS (Centers for Medicare and Medicaid Services) established a general standard of within 30 minutes before or after the scheduled time for non-critical medications. However, always follow your specific facility's written policy — not all agencies use the same window.

Discontinuing or Changing Orders

If a prescriber discontinues a medication order, note the discontinuation on the documentation as "discontinued" or "D/C." For electronic MARs: block further access to times and dates remaining on the MAR for that medication.

Blister Packs and Medication Record Binders (MRBs)

Many agencies use pharmacy-filled blister packs or Medication Record Binders (MRBs) to organize client medications by date and time. Key rules for MRBs:

• Cross-check the MRB/blister pack label with the physician order, the MAR, and the pharmacy label
• Fill the MRB in a safe, quiet, secured area free from interruptions — distractions cause errors
• Fill the MRB for only one client at a time (Right Client)
• Wash hands and wear gloves
• Inspect the MRB prior to filling for cleanliness and good repair

Day Packs & Trip Packs

When a client will be away from their usual residence for a portion of the day or for an outing, their medications may be transported and administered using a day pack or trip pack — a pre-filled, labeled container of medications for that specific outing.

Rules for Day/Trip Packs

• Day/trip packs must contain only the medications the client will need during the outing — based on the current physician's order and the time period of the outing
• Each pack must be clearly labeled with the client's full name, medication name, dose, route, and time(s) to be administered
• The person administering medications during the outing must be a qualified QMAP
• Medications in a day/trip pack should be prepared from the original pharmacy container or MRB — never from another client's supply
• Controlled substances in day/trip packs must be accounted for before and after the outing — document what was administered and what was returned
• Return any unused medications when the client returns; document accordingly
• PRN medications may be included in a trip pack only if they are in their original pharmacy container — PRN medications should NOT be pre-portioned into a trip pack

Documenting an Error

When a medication error occurs, documentation must be specific. Both the MAR and any agency-required incident report forms must include:

• Date and time the error was discovered
• Who you notified and the time of notification
• Detailed circumstances of what happened
• Observed client reactions
• Whether emergency services were called

Communication & Common Abbreviations