If a resident refuses his medication, what should be documented on the MAR?

Documentation on the medication administration record (MAR) is crucial for maintaining accurate records of a resident's medication regimen, especially in cases of refusal. When a resident refuses medication, it is important to document this event clearly and accurately to ensure that all staff are aware of the refusal and the reasons behind it, if any.

By circling the initials and explaining the refusal on the back of the MAR, caregivers ensure that there is a formal record of the refusal. This documentation is essential as it provides transparency and continuity of care. It informs other staff members who may administer medications later, and it can also be valuable information for medical professionals who assess the resident’s health and medication compliance over time.

In addition to compliance with regulations, proper documentation helps to manage the care plan for the resident, allowing healthcare professionals to amend their approach if necessary. For example, they could explore reasons behind the refusal, assess for side effects, or engage in conversations about concerns the resident may have regarding the medication.