Post on 12-May-2022
cMAR Order Transcription
Education
January 2015 D. Johnston D. Elsayed A. Eichler
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Objectives
• To review knowledge surrounding proper medication administration practices and procedures
• To review standards for cMAR documentation.
• To demonstrate the process of transcribing orders using the cMAR according to policies and procedures of Rouge Valley Health System.
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Why cMAR ? When do errors occur?
Prescribing
28%
39% occur
Transcribing
11%
Dispensing
10%
Administering
48% intercepted 12% occur 38% intercepted 11% occur
34% intercepted
51%
38% occur 2% intercepted
• To reduce incidence of transcription errors Percentage of errors that cause harm %%
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Education guidelines • Meditech training Knowledge
• Order transcription class
Skills • cMAR inservice • Self‐learning package
Abilities • Practice • Quiz
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cMar Transcription
Principles:
Legal record of drug administration
Important part of quality and continuity of care
Nurses are accountable for the accuracy and completeness of the medication administration record.
Collaborative process: Nursing and Pharmacy responsibilities
Transcription process follows existing policies and procedures
Transcription / documentation policy
Medication administration times
Approved abbreviations
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Chart forms of the cMAR: cMAR: Computer generated document that is the legal
record of drug administration.
The medication administration record will include: • SCHEDULED and PRN pages
1. Patient specific cMAR
2. Blank cMAR – Downtime forms OR from Meditech
3. cMAR Templates – unit specific
• Will also include
1. Expired medication list
2. Deactivated medication list
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Med
ication en
try
Dem
ograph
ics Allergies
Date range
Prescription number
Type of cMAR
Time columns
Dose supplied Dose ordered
Comments
Start /stop date
Time drug is due
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Other forms….
Deactivated (Hold) list & Expired list • Printed each day with the
patient’s cMAR • Used in the medication
review process • To be placed in front of chart
with DOCTORS ORDER FORMS for physicians to look at
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cMAR TEMPLATES (PRN and SCHEDULED pages)
• Available for select order sets and protocols
1 - 2
dd/mm/yy dd/mm/yy
Transcribe all medications from the order set
A. Nice BA UR
Not ordered dd/mm/yy BA RN
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Epidural / PCA orders • cMAR templates are available
for specific order sets and protocols
• New orders can be transcribed using the templates
• Activate all medications that have been ordered – Start date – Enter information when
prompted • Cross off those medications
that have not been ordered • Sign for STAT and single dose
meds that have been given and then discontinue them
Not ordered 30/11/2014 AE Rn
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Guidelines and expectations: • Transcribe medications as per documentation and
transcription policies – cMAR Policy ADMIN‐PP‐320 – Order Transcription Policy ADM‐PP‐130
• Communicate new orders to pharmacy ASAP – Once entered into the Pharmacy Module in the Meditech system the medication orders will be included on the next printed cMAR.
• Daily cMARs will automatically print on each unit – time will vary between units
• Units have to ensure printers are prepared with adequate paper and toner
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Guidelines and expectations: • Medication orders not entered by Pharmacy into Meditech will need to be manually entered in the next available blank entry section of the cMAR – This applies to new admissions and new orders
• All manually transcribed orders are to be verified and co‐ signed by a nurse before they are carried out
• Ensure all pages are numbered in sequence and present (last page indicated by ‘FINAL PAGE’)
** Remember: Medications are prepared and administered only from entries that have been reviewed and verified as accurate. **
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Transcribing new orders: Select the
appropriate cMAR form
PRN/SCHEDULED/TEMPLATE
Identify the cMAR by the patient’s name number,
allergy status and current date
Transcribe medication into the next blank entry space Place your initial in the “M” column on the Ordering Practitioner’s Form
Complete all prompts
Transcriber initials / verifier initials
Add scheduled times in the appropriate time column
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Components of the BLANK cMAR for manual entries
Drug name Prescribed dose to be given
Route of administration when to give Special considerations: label comments
Start date
Stop date
Prescriber Transcriber
Verifier
1st line – initials of transcriber /
NURSE 2nd line – initials of verifier
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Admissions during pharmacy hours
• Pharmacy will enter the medication orders into the pharmacy module of Meditech
• Once all medications have been verified as entered through Meditech by Pharmacy, or as per unit routine, the cMAR can be printed on the unit
• The cMAR entries must be reviewed and verified as accurate and complete against the patient’s orders
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Admissions after pharmacy hours Select the appropriate
cMAR form PRN/SCHEDULED/TEMPLATE
Identify the blank cMAR by the patient’s name number, allergy
status and date
Transcribe medication onto the blank cMAR
Place your initial in the “M” column on the Ordering Practitioner’s Form
Complete all prompts
Transcriber initials / verifier initials
Change 1900 AE RN Only applies to 1 Day cMARs
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Working with the cMAR: Discontinue an existing medication order
Discontinued 27/09/2014 BA R.N.
• Order received to discontinue the drug • Changes to dose, route, frequency is considered a new order • NOTE: D/C is not an approved abbreviation
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STAT and single dose medications
• Transcribe STAT or single dose orders in the SCHEDULE MEDICATION cMAR. – STAT medications should also signed on the original order at the time of administration.
– Notify Pharmacy of STAT medication orders as per unit routine.
• Once given, record administration, discontinue the medication
Lasix 40mg
IV Give STAT
Dr. Green
STAT TT BY
12/03/2014
12/03/2011
0900 AE
Discontinued 12/03/2014
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Amending an existing medication order
Target MAP above 60
30/08/14 BA RN
• Changes to comments or instructions • i.e. clinical parameters
• Medication reorder: amend the start and stop dates
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Future dates
• Future date (other examples: Q72H, Q4days) will indicate when the medication will be due
• Time for administration will appear in the appropriate time column on the day the medication is due
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Hold and suggest orders
• HOLD orders have a specified duration and a direction at the end of the HOLD period – i.e. “hold Lasix for 3 days and restart”
• The medication entry is marked “HOLD”
• Suggest orders are not transcribed until confirmed by the most responsible physician
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IV infusions with medications
• Intravenous infusions with additives • Transcribe the additive to the SCHEDULED MEDICATIONS
cMAR. Routine administration times are not indicated.
• When the new bag is hung document time and initials
0200 BN
Example: IV normal saline with 40mmol/L KCL
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Saline Lock • Saline lock flushes are Q8H • Documented on the SCHEDULED cMAR • Flushing of CVAD (Q7days) is also documented on the SCHEDULED cMAR
Q8H times Add time and initials for
flushing before and after meds etc.
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Tapering doses of medications Manual entries: the tapering directions are transcribed into the comments section cMAR entries: each tapered dose will appear as a separate entry • Pharmacy module will calculate which dose is due for
each day • The dose due will have the time noted
• Each successive dose will indicate “future date”
E.g. Nicotine Patch 14mg/day then Nicotine Patch 7mg/day
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Diabetic medication orders
• Insulin and Antidiabetic medications are on the SCHEDULED MEDICATION cMAR
• Documentation of administration is on the Diabetic Protocol Sheet
Sliding Scale Insulin times of administration are noted here, but sign on the diabetic protocol
sheet
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Anticoagulation medication orders • Anticoagulant medications – SCHEDULED cMAR • Administration times (if appropriate) are noted in the time columns
• “see Anticoagulation Dosage Record” needs to be manually written into medication columns.
Sign on the anticoagulation dosage
record
Warfarin Orders: Dosages to be recorded on Anti‐coagulant sheet to avoid double
documentation.
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– Amino Acids– Amino Acids #
TPN • New TPN orders are manually entered into the
next blank entry section SCHEDULED cMAR • Amino Acid and Lipids are treated as 2 separate
orders • For rates < 2000ml/24H with ingredients added
daily there will be 2 different amino acid solutions
#1 (with daily additives) 2 (without daily additives)
The pharmacy module will list
all the ingredients
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Some medications may be dependent on or linked to others Examples: 1. If one medication has to be given
before or after another 2. If medications have different
forms but either can be given. 3. If two medications or different
dosages of medications must both be given to make up total dose ordered
The cMAR will note the linked prescription number across the time columns When transcribing these medications into the next blank entry space note the conditions in the comments section
Linked prescriptions
����������� ������� ���
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Stop Date Odds and Ends
• Medication specific time frame follows stop date policy – All medications have a maximum 90 day stop date
• Orders missing the scheduled time may be “expired” Auto‐substitution Orders (policy M‐0035)
• Transcribe the Automatic Substitution Form and discontinue the previous order
Even / Odd Day Dosing • Medications will appear on the cMAR even when not scheduled
– If there is no time of administration the medication is not due • For even/odd day dosing ‐ the same dose is given on two consecutive days
when there are 29 or 31 days
Medical Directives • Write the order on the Ordering Practitioner Order Sheet
– Transcribe the order in the next blank entry space on the SCHEDULED cMAR
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Nitroglycerine Patches: • MARs will not show “off”
Odds and Ends Continued
• When verifying MARs write in “off” so removing patches is not missed (e.g for Q12H)
TEDS & Pneumatic Compression devices will display on the cMAR Highlighting: • Feel free to highlight MARs to assist in making information more clear
• Doses – confusion with doses vs. concentration • PRN or SCHEDULED MAR
Filing System • Charts and MARs MUST stay together on floor • May use filing cabinet to file charts for easier retrieval to look at old
MARs if needed • All Charts should stay on unit until patient is discharged
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Integrated Unit Processes Integrated units will have both a 7 day and a 1 day cMAR in use • 1 Day cMARs for acute patients • 7 Day cMARs for CCC or post‐acute patients • Every patient on the unit will have a 1 day cMAR printed out
each night • The CCC and post‐acute patient 1 day cMARs will need to be
shredded, as they only need a new cMAR every 7 days
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Using the 7 day cMAR Continued… When the 7 Day cMAR is finished (i.e. the nurse should recognize on the last day of the cMAR a new one will need to be printed – similar to past procedure). 1. Manually print the 7 Day cMAR from Meditech
following printing instructions 2. Verify the cMAR as per procedure 3. Begin using new 7 Day cMAR
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Manually Print cMAR: Printing Connect to the Meditech system
and select 1 for Live Enter ID and Password cMAR PRINT ROUTINES
screen
‘300’ to print the cMAR
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How to print the cMAR for all patients on the unit:
Order Entry in Meditech: from PRINT ROUTINES menu
Unit location F9 Look‐up ‘Name’ & ‘Printer’ will auto populate
Verify date ‘T’ for MARs active from
2300 onwards to
2259
INP (inpatient)
Select MAR format F9 look‐up
Scroll and select RVC.MAR 1 RVC MAR – 1 Day
? Queue to print
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How to print the cMAR for one patient on the unit:
Order Entry in Meditech INP (inpatient)
This space remains empty
Select patient F9 Look‐up ‘Status’, ‘age’ & ‘Printer’ will auto populate
Select MAR format F9 look‐up
Scroll and select RVC.MAR 1 RVC MAR – 1 Day
Verify date ‘T’ for MARs active from 2300 onwards to 2259
Select printer ? Queue to print
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How to print blank SCHEDULED or blank PRN cMAR pages for one patient on the unit:
initial steps are the same as printing the patient specific cMAR until selecting patient and the cMAR format
INP (inpatient)
Select patient F9 Look‐up ‘Status’, ‘age’ & ‘Printer’ will auto populate
This space remains empty
Select MAR format F9 look‐up
Scroll and select either BLANK SCHEDULED CMAR BLAND PRN CMAR
Verify date ‘T’ for MARs active from 2300 onwards to 2259
‘T‐1’ for now
Select printer
? Queue to print
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Planned Downtime Print patient specific cMARs early
Downtime
Blank cMAR forms for new admissions and new orders ‐ manual transcription
Communicate with Pharmacy
Unplanned Downtime Blank cMAR forms for new admissions and new orders for manual transcription
Communicate with Pharmacy
Return to Live Communicate with Pharmacy – enter medications into the pharmacy module
cMARs will print at the usual time
Downtime cMAR Policy ADMIN PP-330
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CHART CHECK
• The night nurse is responsible for checking that all orders for the past 24 hours have been transcribed appropriately and are signed off on the Ordering Practitioner Form.
• If any orders are not initialed or not signed off at the bottom of each set of orders, the nurse is required to complete the transcription process. The nurse performing the chart check will stamp below the most recent orders verifying that the process has been completed.
24 hour chart check 25/11/2014 2330
B. A. Nurse
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Verification process Newly printed cMARs must be checked and
verified!
Review each section: demographics / medication entries Verify each page for accuracy and completeness. Ensure: 1. All discontinued meds are not on the
current cMAR 2. All new orders are on the cMAR May need to manually transcribe
Note: Medications ordered after the pharmacy department has closed will not appear on the new cMAR. The medication will
need to be recopied onto the new cMAR and cosigned.
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Discrepancies Confirm the medication entered with the original order and hand write the correction in the next blank entry box on the cMAR and communicate to pharmacy using the MAR Communication Form.
This form is NOT optional, it is necessary to correct ALL errors found on cMAR.
***Medications are prepared and administered only from entries that have been reviewed and
verified as accurate.***
Nursing Treatment Record
Nursing Treatment Records can be used for items not captured in the cMAR, including: Beneprotein, MedPass, dressing changes, feeding tube flushes, etc.
Will be used for 7 days and can be kept with the cMAR Obtained from Print Shop (not Meditech) Three options available: Blank, Oral and Enteral Supplements
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Patient Transfers Involving cMARs
a) If transfer involves a change in acuity, the sending unit should print out the medication and treatment form prior to transfer; following the medication reconciliation policy
b) Ensure physician reviews medications as needed c) Transcribe all new medication orders from the
ordering practitioner’s form onto the patient's cMAR.
Please Note: in some cases, the nurse/unit clerk may wait for pharmacy to enter orders before they print the cMAR to prevent unneeded manual transcription
***Medications are transcribed only from Orders, not recopied from the existing MAR***
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Questions
Rap‐up
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References • College of Nurses of Ontario (CNO) Legislation and Regulation RHPA: Scope of Practice, Controlled Acts Model.
http://www.cno.org/docs/policy/41052_RHPAscope.pdf
• Edmunds, M.W. (2000). Introduction to Clinical Pharmacology . Mosby: Toronto
• George Brown College Nursing Department, Faculty of Health Sciences. NURSING 1012 Nursing Practice II. 1984
• Harwood, J. and Lumsden, J. Transcription of Physician Orders. Toronto East General Hospital. October 2001.
• National Association of Pharmacy Regulatory Authorities (NAPRA) (2009). Model Standards of Practice for Canadian
Pharmacists. http://www.ocpinfo.com/client/ocp/OCPHome.nsf/web/Model+Standards+of+Practice
• Robinson, J. Medication Administration 2002. Durham College NUR2512-NRC Nursing Program.
• Rouge Valley Health System Medication Policies
• Rybenko,L. RVHS-CHC Transcription of Physician Orders. June 1996. Revised April 2000 by Lim, C.
• Tse, D. Centenary Health Centr e T r ans c r ibing Phys ic ians ’ O r der s . “ An Information and Self-Directed Learning
Package for the RPN and Unit Clerk in Preparation for the Classroom Training in Order Transcription” . November 1995.
Revised June 1996 by Rybenko, L.