Medication records

12.1

All medication may cause harm if it is not administered according to the prescriber’s or manufacturer’s instructions.  Carers should not provide support with medication until they have all the information set out in this section.  

12.2

All medications – the person’s record must include these details.

• the full name and date of birth of the person to whom medication is to be administered   
• any known drug sensitivities e.g. to penicillin, aspirin   
• the name of the medication to be administered
• the reason why the person is taking the medication
• the form of the medication e.g. tablets or liquid   
• the amount in the bottle/container supplied to the home / day centre 
• the strength of the preparation   
• the required dose   
• the route of administration e.g. by mouth   
• the time(s) the medicine is to be administered   
• any special instructions e.g. whether it should be given before or after food 

12.3

When a person has as required medications – the person’s record must include an individualized PRN protocol, PRN MAR sheet, details listed in 12.2 and these additional details: the circumstances in which the medication is to be given • how much medication is to be given 

• what the medication is expected to do, for example help them breathe more easily
• whether a dose can be repeated and if so:
• the minimum time between doses if the initial dose has no effect, and
• the maximum dose which can be taken within 24 hours  

12.4

Variable dose medications - Prescribers may alter the dose of a variable dose medication following a blood test.  

12.5

If the person has had a blood test and no advice has been received from the prescriber, carers must check with the prescriber to see if the dose has changed. If it has, carers must ask the prescriber to confirm the correct dose in writing and update the person’s record. 

12.6

Over the counter products –  These may be provided for general use in some services or may be brought into the service by family.   

12.7

Carers must check with the person’s GP or a pharmacist about whether an over the counter product might interact with a prescribed medication.   Carers must record the advice in the person’s record and where relevant discuss the advice with the person and / or their family. This should be recorded on the back of the MAR sheet and make reference where required in carer logs.  

12.8

If any of the above is missing, the carer must notify the healthcare professional and GSL.  

12.9

Carers who provide any level of medication support will maintain up to date medication records. This will include:

• a medication administration record (MAR sheet) or PRN MAR sheet (where applicable) for each prescribed / non prescribed medication that the person takes. Carers will complete the MAR sheet as required by the GSL MAR protocol
• the most up  to date medication protocol and where relevant information about the content of a dosette box
• the most up to date patient information leaflet for each current medication
• any record book issued for medication where dosage is dependent on blood test results (for example warfarin, lithium) 
• any other necessary information about a current medication 

12.10

All medicines administration records should:

• Be legible
• Be signed by the competent person administering medication
• Be clear and accurate
• Clearly indicate medication stock levels
• Have the correct date and time (either the exact time or the time of day the medicine was taken)
• Be completed immediately after the person has taken the medication;
• Avoid jargon and abbreviations 
• Changes to typical and expected medication administration should be recorded on the reverse of the MAR sheet (e.g – medication spoiled, new medication stock added, refusal to take medication, handover to other services, or shared lives carers)

12.11

GSL will monitor medication records through routine audit processes, monthly medication audits and  regular monitoring  visits. This includes unannounced  visits to the shared lives placement. 

12.12

Carers will share information / ensure access to PRN MAR/ MAR sheets for each current medication with the person and their medication(s) whenever the person moves between the main and other carers or from one GSL arrangement to another:  

• For example – when someone moves between GSL carers, the current GSL carer must inform the next carer of any medication administered prior to the handover – including time and dosage

12.13

The main carer will immediately make required changes to keep the person’s medication record up to date at all times, in line with UK GDPR and the Data Protection Act 2018. 

12.14

When a GSL arrangement comes to an end and the person is no longer being supported by a particular carer (for example when the person moves to another permanent arrangement or dies) the carer will return any paper medication records to GSL.  

12.15

GSL will hold medication records in line with current data protection requirements and will review the record after 8 years. If the record is no longer needed, it will be securely destroyed.