Medication Administration Record

Medication Administration Record (MAR) – Scheduled and PRN Name: John Member Month: December Year: 2016 Allergies: Penicillin CLI H&W Coordinator: Mary Smith, RN AFH: AFH Provider Name AFH Medication Orders Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Name, Dosage, Route: Docus 8 AM CP CP CP X CP CP CP CP CP CP CP CP CP CP CP ate Sodium 100 mg 1 capsule every day by mouth Reason: Stool softener

Name, Dosage, Route: Linsin 8 AM CP CP CP CP CP CP CP CP CP CP CP CP CP CP CP opril 10 mg 1 tablet every day by mouth Reason: high blood pressure

Name, Dosage, Route: Lovast atin 20 mg every day by mouth Reason: High Cholesterol 8 PM HP HP HP HP HP HP HP HP HP HP HP HP HP HP HP

Name, Dosage, Route: Aceta HP CP minophen 325 mg 1 to 2 tabs every 4 hrs as needed by mouth Reason: Fever, pain

Name, Dosage, Route: HP HP Tums Regular, 500 mg: 2 tabs by mouth every 4 hrs as needed. Reason: Indigestion, heartburn

1 Adapted from APD Form 65G7-00, adopted 3/10/08 by Rule 65G-7.001(13), F.A.C. 2/16/2017

Medication Orders Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Name, Dosage, Route: Reason:

Name, Dosage, Route: Reason:

2 Adapted from APD Form 65G7-00, adopted 3/10/08 by Rule 65G-7.001(13), F.A.C. 2/16/2017 Staff Signature Initial Signature Initial Signature Initial Charles Provider CP Heather Provider HP

Resident Name: John Member Month: December Year: 2016 If medication not administered, enter an “X” in the time scheduled. Then provide additional information using the codes in the box at the left in the record below

Comments – Reason Medication Not Given REASON MEDICATION NOT ADMINISTERED Date/Time Reason Comments/Explanation Staff (Select Code) Initials 1 = Refused 12/14/16 5 Member having loose stools- hold per Dr. Jones CP 2 = At Substitute Care 3 = ER/Hospital 5 = Held by MD 6 = Missed available 8 = Other: Explain Time, date, and initial Sign and initial at the

3 Adapted from APD Form 65G7-00, adopted 3/10/08 by Rule 65G-7.001(13), F.A.C. 2/16/2017 PRN (As Needed) Medication Administration Log Initial Medication as given on MAR and complete as directed below:

Name: John Member Month: December , Year: 2016 Allergies: Penicillin CLI Health & Wellness Coordinator: Mary Smith, RN AFH: Provider Name AFH

DATE/TIME MEDICATION NAME, REASON MEDICATION GIVEN RESPONSE TO MEDICATION STAFF DOSE, & ROUTE (What effect(s) did it have for the resident?) INITIALS 12/1/16 Acetaminophen Headache - rates pain 4/10 9:45 pm - member sleeping HP 9:15 PM 325 mg - 2 tabs by mouth 12/4/16 Acetaminophen left ear pain - rates pain 3/10 8:00 am - member rates pain 0/10 CP 7:30 AM 325 mg - 1 tab by mouth 12/10/17 Tums Regular, 500 Heartburn - Rates as 5/10 7:30 pm - member rates heartburn at HP 7:00 PM mg: 2/10 2 tabs by mouth every 4 hours as needed 12/15/17 Tums Regular, 500 Indigestion - Rates as 6/10 7:30 pm - member rates heartburn at HP 7:00 PM mg: 0/10 2 tabs by mouth every 4 hours as needed

4 Adapted from APD Form 65G7-00, adopted 3/10/08 by Rule 65G-7.001(13), F.A.C. 2/16/2017 Directions for Use – MAR and PRN Log

The Medication Administration Record (MAR) should be set up at least monthly and updated with any medication changes by staff trained in medication management. The MAR should always be double checked to ensure accuracy.

The MAR should list all Scheduled and As Needed or PRN medications:  Each scheduled medication should include the medication name, dosage, route, and administration time(s) as ordered by the resident’s medical provider. Please also include why the medication is being prescribed for the resident (reason) and possible side effects of the medication so staff can monitor for these effects.  All As Needed or PRN medications should include medication name, dosage, route, and administration directions for as needed administration. Please also include why the medication is being prescribed for the resident (reason) and possible side effects of the medication so staff can monitor for these effects.

Complete MAR Form EACH DAY. Enter your initials in box immediately after medication administration.

Complete PRN (As Needed) Log immediately after PRN medication administration, include full medication name, date and time of administration, the reason for administration, and staff initials. After 30 minutes, check with the resident and document the resident’s response to the medication. Did the resident respond as expected with the medication indication?

Submit this form to the member's CLI office by the 5th of the following month via fax, postal mail, or drop off:

CLI Office Email Address Fax Number Mailing Address Blair [email protected] 608-785-5331 PO Box 167, Blair, WI 54616 La Crosse [email protected] 608-785-6315 1407 St. Andrew St., Suite 100, La Crosse, WI 54603 Mondovi [email protected] 608-785-5332 697 East Main St., Mondovi, WI 54755 Neillsville [email protected] 608-785-5333 PO Box 190, Neillsville, WI 54456 Sparta [email protected] 608-785-5330 PO Box 254, Sparta, WI 54656

5 Adapted from APD Form 65G7-00, adopted 3/10/08 by Rule 65G-7.001(13), F.A.C. 2/16/2017