Charting accuracy of scheduled medications in the medication administration record.
This study was designed by the pediatric clinical pharmacy service to evaluate the accuracy of the nursing Medication Administration Record (MAR). Medications returned to the pharmacy in the exchanged medication carts were compared to those charted in the computer-generated MAR for 10 working days. Fourteen percent of the doses studied were categorized as charting errors. Charting inconsistencies were summarized in a personalized memorandum distributed to the nursing staff on the pediatric unit. A subsequent evaluation revealed a 10% charting discrepancy rate. The nursing memo did not effect a statistically significant change in the error rates between the two phases of the study. Inaccurate charting poses problems for therapeutic decision making and for methods of reimbursement that use the MAR. This problem should be assessed in individual institutions. Corrective measures should be implemented and evaluated.
D004282:Documentation / Q000592:standards*; D005069:Evaluation Studies as Topic; D008499:Medical Records / Q000592:standards*; D008510:Medication Systems, Hospital / Q000592:standards*