MAR/EMAR Audit

A Medication Administration Record (MAR) / Electronic Medication Administration Record (EMAR) MAR/EMAR  Audit Checklist using eAuditor Audits & Inspections can help ensure that medications are being properly administered and recorded in compliance with healthcare regulations.

1. General Information

• Audit Date: [Date]
• Auditor Name: [Name]
• Location: [Facility Name]
• Department: [Department]
• Shift Audited: [Shift Time]

2. Documentation Review

• 2.1. Patient Information
  • Is the patient’s full name, date of birth, and ID clearly documented on the MAR/EMAR ( MAR/EMAR Audit ) ?
  • Are allergies or adverse drug reactions clearly noted in the record?
• 2.2. Medication Orders
  • Are all medication orders current and signed by an authorized prescriber?
  • Is each medication’s dose, route, frequency, and duration clearly documented?
  • Are PRN (as-needed) medications clearly indicated with specific administration guidelines?
• 2.3. EMAR System
  • Does the EMAR system display up-to-date information for all active medications?
  • Are there any discrepancies between MAR and EMAR (MAR/EMAR Audit) records?

3. Medication Administration Process

• 3.1. Five Rights of Medication Administration
  • Is the “right patient” being confirmed before each medication is administered (using two identifiers)?
  • Is the “right medication” being confirmed with the prescription label and MAR/EMAR?
  • Has the “right dose” been administered as prescribed?
  • Is the “right time” adhered to, and are any delays in administration documented with reason?Hs
  • Is the “right route” (oral, IV, IM, etc.) followed as prescribed?
• 3.2. PRN Medication Administration
  • Are PRN medications administered only when indicated, and is the reason documented?
  • Document PRN outcomes  (e.g., effectiveness or adverse reactions)?

4. Controlled Substances

• 4.1. Controlled Medication Documentation
  • Document  controlled substances appropriately in the MAR/EMAR (MAR/EMAR Audit)?
  • Is there a dual-signature process for controlled substances as required?
  • Are inventory counts of controlled substances accurate and up to date?
• 4.2. Storage and Security
  • Store controlled substances in a secure, locked area?
  • Is access to controlled substances restricted to authorized personnel?

5. Medication Timing and Frequency

• 5.1. Scheduled Medications
  • Administer medications within the appropriate time window (e.g., 30-60 minutes before or after the scheduled time)?
  • Are any late doses or missed doses documented with appropriate reasoning?
• 5.2. Medication Frequency
  • Give medications at the correct frequency (e.g., once daily, twice daily).
  • Administer medications requiring specific timing (e.g., before meals, bedtime) at the correct intervals.

6. Missed, Refused, or Held Medications

• 6.1. Missed Doses
  • Document for missed doses with the reason for omission.
  • Are physicians notified of missed doses when required?
• 6.2. Refused Medications
  • Document for patient’s refusal of medications, including the reason for refusal.
  • Communicate refusals  to the healthcare team and manage according to policy?
• 6.3. Held Medications
  • Are any held medications documented with the reason for withholding?
  • Is there proper documentation of physician approval or notification when medications are held?

7. MAR/EMAR Updates and Changes

• 7.1. Medication Changes
  • Are changes in medication (new orders, dose adjustments, discontinuation) reflected accurately in the MAR/EMAR?
  • Are prescriber orders followed promptly, and are changes signed by authorized personnel?
• 7.2. System Alerts
  • Are EMAR alerts for medication interactions, allergies, or duplications being addressed appropriately by staff?
  • Is there documentation showing that alerts have been acknowledged and managed?

8. Documentation and Record Accuracy

• 8.1. Documentation Completeness
  • Are all fields in the MAR/EMAR completed (e.g., time, date, initials of the administering nurse)?
  • Are corrections to the MAR/EMAR clearly marked with an explanation (no alterations without documentation)?
• 8.2. Legibility and Accuracy (For Paper MAR)
  • For paper-based MARs, is handwriting legible and free from ambiguous abbreviations?
  • Are all doses, signatures, and notes clear and accurate without errors?
• 8.3. Digital Signatures (For EMAR)
  • Use digital signatures appropriately in the EMAR to verify administration.
  • Are any discrepancies between manual and electronic records reconciled?

9. Medication Storage and Disposal

• 9.1. Medication Storage Conditions
  • Store medications stored according to manufacturer guidelines (e.g., refrigeration, light-sensitive)?
  • Are multi-dose vials dated upon opening and used within their expiration window?
• 9.2. Expired Medications
  • Are expired medications removed from storage and disposed of according to policy?
  • Is there a system for regularly checking for expired medications?

10. Patient Education and Consent

• 10.1. Informed Consent
  • Are patients or their representatives informed about the medications they are receiving?
  • Is there evidence of informed consent for new or high-risk medications (if applicable)?
• 10.2. Patient Education
  • Are patients educated about the purpose, potential side effects, and dosage schedule of their medications?
  • Is patient education documented in the MAR/EMAR or separate patient notes?

11. Compliance with Policies and Protocols

• 11.1. Hospital/Facility Policies
  • Is medication administration performed in line with the facility’s policies and procedures?
  • Are staff aware of and compliant with infection control protocols when administering medications (e.g., hand hygiene, glove use)?
• 11.2. Regulatory Compliance
  • Is the facility compliant with local, state, and federal medication administration regulations?
  • Are required audits conducted regularly, and is non-compliance addressed immediately?

12. Final Review and Comments

• 12.1. Summary of Findings
  • Are there any critical findings or recurring issues that require immediate action?
• 12.2. Corrective Actions
  • Have corrective actions been assigned and documented for any issues found during the audit?
• Sign-off by Auditor: [Signature]
• Date of Next Audit: [Scheduled Date]

Key Features for eAuditor Audits & Inspections Integration

1. Customizable Templates: Easily customize the template to reflect the specific needs of your facility.
2. Automated Alerts: Set up alerts for medication errors, missed doses, or discrepancies.
3. Action Assignment: Automatically assign corrective actions and monitor follow-up on non-compliance.
4. Data Analytics: Use eAuditor Audits & Inspections’s analytics feature to identify trends in medication errors or non-compliance.
5. Real-time Reporting: Generate and share reports with stakeholders directly from eAuditor Audits & Inspections once the audit is completed.

This checklist will help ensure compliance, improve medication safety, and maintain accurate records. It can be tailored for paper-based MAR systems, electronic EMAR systems, or a combination of both.