20.1 The council has a duty to keep records for each person using its services.
20.2 Staff must maintain complete, accurate and up to date records of all medication related activities as required by local procedures.
20.3 The council use electronic social care records for people accessing our services.
20.4 Some times, staff transcribe the MAR sheet, once they have specific and annually review training to do so. Transcribing is the process of copying medication information from an authorised source onto a Medication Administration Record (MAR) and carries an increased risk of error. Any transcribing must:
- be copied exactly from two of the following authorised sources:
- the original pharmacy dispensing label
- a written prescription
- a written medication instruction or protocol from an appropriate health professional
- include, as a minimum:
- the name of the medication
- strength
- dose
- route of administration
- timing or frequency
- be:
- clearly marked as transcribed information
- signed and dated by the person who transcribed it
- independently checked and countersigned by a second competent member of staff before the medication is administered
20.5 Transcribing must never be undertaken from:
- verbal instructions alone
- memory
- photographs of medication labels
- previous MARs unless they are confirmed as current and accurate against an authorised source
20.6 Where paper-based records are used, they must be legible, completed in black ink, dated and signed by the person making the entry. Errors must be corrected by ruling a single line through the incorrect information so that the original entry remains legible. Staff must then record the correction and date and sign the record.
20.7 Regardless if the information is paper based or electronic, we will keep information secure and use it in accordance with council Privacy Notices and the UK GDPR and Data Protection Act 2018.
