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CMAR

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Title: CMAR


1
CMAR
  • Computerized and Printed
  • Medication Administration Record

CMAR
2
Learning Objectives
  • At the end of this module, the student will be
    able to
  • 1.Discuss the differences between the current
    5-day MAR and the new pre-printed daily CMAR
  • 2.Verify CMAR accuracy
  • 3.Document medication administration or omission
    on the CMAR
  • 4. Discuss the utilization of Kardex for
    non-medication orders
  • 5. Explain how to complete and when to use
    variance form

3
CMAR
  • When January 23, 2006
  • Where Housewide
  • Who Nurses, AAs, RTs and Prescribers
  • IS and Pharmacy are also involved

CMAR
4
And Why?
  • CMAR Benefits
  • To optimize the medication administration process
    by utilizing standard administration times
  • To reduce number of missing doses
  • To enhance pharmacy-nursing collaboration
  • To promote patient safety by improving accuracy
    of CMAR and reducing transcription errors
  • To help us to prepare for EMAR and CPOE

5
CMAR Basics
  • The CMAR will cover administration from 0700 on
    the current day to 0659 on the following day (1
    day)
  • Nurse completes variance report when the variance
    is noticed in the computer (real time)
  • CMARs print on unit every day at 0100
  • Nurse verifies the accuracy of the new CMAR after
    it prints at 0100
  • When there is no space available on the CMAR,
    blank CMARs should be used
  • Any orders or changes in orders after 2300 will
    be hand transcribed
  • new medications should be hand transcribed onto
    the existing CMAR as well as on the next days
    CMAR

6
CMAR Appearance
  • There will be 2 CMARs for each
  • patient routine meds and prn/stat meds
  • both copies will be white
  • CMAR will not be double-sided
  • there will be a separate CMAR
  • for sliding scale insulin
  • The generic name will appear with the trade name
    in parenthesis
  • Frequency and hours of administration will both
    be included
  • standard medication times will be used
  • antibiotic catch up grid will be used
  • Approved substitutions will be provided for
    ordered meds

7
CMAR Appearance (contd)
  • You will see patient height, weight and allergy
    information included on the CMAR
  • this information will be entered into Cerner by
    PCA (Ht/Wt) and Nurse (Allergy)
  • if the patient has too many allergies, the CMAR
    will state Print kardex for the allergies. Be
    sure to print Kardex and place it in the med
    book, so it can be referred to by anyone
  • Qualifying information (ex. Hold HRlt60) ordered
    by Prescribers will be included
  • Automatic Stop dates will be pre-printed
  • ex. prn Narcotics need to be re-ordered every 7
    days
  • Administrative notes (directions) will be be
    displayed

8
Example of CMAR (scheduled medication section)
CMAR will have more information for clinicians-
DOB, admitting dx, ht, wt, allergies
CMAR provides clinicians with approved
substitutions for ordered medications
CMAR provides additional information to the
clinicians about administration
9
Example of CMAR (scheduled medication section)
10
Example of CMAR-PRN medication section
11
Example of CMAR-SSI medication section
12
Administrative Notes
  • Be sure to read all administrative notes
  • Dosage A medication might appear that you do not
    think is ordered because it is added to another
    medication to make the dose ordered. For example
    a patient is ordered Percocet 10/325 1-2 tabs.
    Our pharmacy only carries the Percocet 5/325
    tabs. So in order to give the dose ordered
    (10mg/325), pharmacy adds oxycodone 5 mg. The
    administrative note indicates to give the two
    drugs together. Because they are two different
    drugs they are listed in separate boxes.

13
Administrative Notes
  • Dose Rounding A physician writes for lovenox 50
    mg. The dose printed on the CMAR is 60 mg. There
    is an administrative note stating per PT
    (Pharmacy and Therapeutics) policy the dose is
    rounded to 60 mg.
  • Dose Description A physician writes for Percocet
    10/650. The dose printed on the CMAR is 2 tabs.
    There is an administrative note stating 2 tabs of
    5/325 10/650.

14
Non-Pharmacy Tasks
  • Non-pharmacy tasks will appear on kardex (e.g.
    dressing changes, tube flushes). Use flowsheet
  • or another appropriate document for
    non-pharmacy tasks documentation.
  • ! Do not document non-pharmacy tasks on
  • CMAR.

15
CMAR Workflow
Written MD Order
Nurse/AA scans order to pharmacy
Nurse reviews AA transcription
Nurse/AA transcribes order onto CMAR
Pharmacy verifies order and enters it into
PharmNet
New Pharmacy Order Notification appears on the
PAL
Nurse reviews order from Nurse Review
Any Variances
Meds sent to floor
No
Yes
Nurse does not apply Review to an order that is
questioned, completes variance form, and sends
original order to pharmacy
Nurse initials the written order sheet and CMAR.
Nurse apply Reviewin the Nurse Review tab
Nurse administers meds
16
Nurse Review
Nurse verifies all of the new medication orders
in computer as the pharmacy enters them into
Cerner. The expected turnover time for pharmacy
order entry is 2 hours (from the time of scanning
till the time of med order appearance in the
Power Chart).
  • Nurse Review Steps
  • Open PAL
  • Click on the eyesglasses icon to view the new med
    order only and then close the window
  • Click on the Orders tab
  • Click the Nurse Review sub-tab
  • Select medication (s) order to be reviewed
  • Review medication by comparing it to the written
    order
  • Click Review button if the order is correct

17
Medication Variance Form
  • All printed medication discrepancies should be
    identified on the Medication Variance Form and
    corrected on the current CMAR (if appropriate).
  • this includes changes to a medication order
    (dose, route, frequency or parameters), allergy
    information or patient weight
  • allergy and weight changes should also be changed
    in Cerner
  • the form should be scanned to pharmacy
  • the variance will be corrected in the Pharmacy
    system

18
Variance Form
19
Medication Variance Form
  • Nurse should leave the original variance form in
    the folder Variance above the fax/scan machine
    (after faxing/scanning)

Variance
20
CMAR Workflow Night Shift
New CMAR prints at 0100
Nurse checks newly printed CMAR for accuracy b/t
0100 0400 by comparing it to the previous days
CMAR and the medication order (check dose,
frequency, times etc)
Present
Newly Printed
Any Variances
Yes
No
Nurse completes variance form and sends it to
pharmacy
Nurse initials the verification column init for
EACH medication
21
Verification of Accuracy
  • A nurse will check each newly printed CMAR for
    accuracy
  • compare it to the previous days CMAR and the
    medication order (check dose, frequency, times
    etc)
  • the nurse initials the verification column init
    for EACH medication
  • a nurse verifies all patient information name,
    allergies, room number, and weight

22
The Pharmacy Alert Notice
  • The Pharmacy Alert Notice Form is still to be
    used when medications are missing from the
    patients medication drawer

23
Filing of CMAR
  • Newly printed CMAR is placed in the MAR binder by
    Nurse
  • The CMAR from the previous day is folded in half
    and kept in the MAR binder
  • Old CMARs (gt 24 hours) are filed in chronological
    order in the patients chart under the medication
    tab

Filing of CMAR
24
Generic or Blank MARs
  • Blank CMARs will be available on the unit
  • scheduled and prn blank CMARs will
  • be available on the unit
  • blank MARs will be used for admission
    and transfer orders or when the
    printed CMAR is full and new medications are
    ordered
  • a patient label is placed in the upper right
    corner
  • allergy and weight are written in the appropriate
    place
  • CMARs should be numbered if there is more than
    one (e.g., page 1 of 2)

25
New Orders on an Existing Patient
  • The medication is hand transcribed onto the
    current printed CMAR (or blank CMAR when current
    CMAR is full)
  • Nurse verifies transcribed order with the
    prescribers order and initials the init box on
    the CMAR
  • Fax/scan ALL orders to Pharmacy

26
Transfers and Admissions
  • Orders DO NOT need to be re-written
    when patients are transferred to
    another unit on the same service with the same
    level of care (ONT to Pulm ID)
  • the same CMAR will be used until the new CMAR is
    generated for the next day
  • enter transfer information into Medipac

27
Transfers and Admissions
  • Orders DO need to be re-written when patients are
    transferred to another unit with a different
    level of care (ICU to Pulm ID)
  • new medication orders will be hand transcribed to
    a blank CMAR and this will be used until the next
    CMAR is generated
  • all medications transcribed by an AA must be
    checked by a nurse (Nurse or LPN) however, all
    IV medications must be verified by a Nurse
  • AA enters transfer information into Medipac and
    notifies Admitting

28
New Admissions
  • Admission orders are
  • transcribed onto a blank CMAR
  • Nurse verifies the transcription with the order
    and initials the initials column of the CMAR
  • Orders are faxed/scanned to
  • Pharmacy

29
Medication Administration Times
  • Medication administration times will be entered
    by Pharmacy and will appear on the CMAR
  • in accordance with the newly (6/04) approved
    times listed in the hospital policy
  • Peds, Psych, Rehab, and NICU do not follow the
    standard hospital dosing schedule
  • example bid and q12 dosing times are now both
    1000 and 2200

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31
Medication Administration Times
  • A prescriber order is required to change the
    standard administration time (the order should
    include the request for change and the new time
    of administration)
  • the revised order will be faxed to
  • Pharmacy and the time changes will
  • appear on the next printed CMAR
  • until the new CMAR prints, the nurse will draw a
    line through the standard time and write in the
    new time

32
Documentation of a Medication Given
  • Nurse or RCP initials on the line next to time
    after the medication is administered
  • Nurse or RCP signs and dates in the signature
    section at the bottom
  • The site of injection is entered after the
    initials using the assigned code number

33
Documenting On/Off Times
  • If drugs are ordered to start and stop at a
    certain time (ex. Nitrate Patch), the nurse will
    initial both events
  • the administration time will print and the nurse
    initials that it was applied
  • the off-time will be printed as a descriptor only
    and the nurse should hand document the off-time,
    initials and the word off

ON OFF
34
Documentation for Unusual Dosing
  • For medications due on odd days/every third day
    etc, the drug will appear daily but the
    administration time will only print on the day
    the the drug is to be given
  • example Fentanyl Patch

Unusual Dosing
35
Double Signature Requirements
  • Two nurses must initial for any
  • medications that require a double-check
  • Reminder statements will be present for all Adult
    and Pediatric Medications that require a double
    signature
  • Double Sign will be seen for all Adult and Peds
    medications that require a double signature
  • For Peds- double sign will be seen for
    Pediatric medications only that require a double
    signature

36
Double Signature Requirements
  • Adult Medications
  • Heparin IV
  • Insulin
  • Chemotherapy Drugs
  • TPN/PPN/Lipids
  • PCA/Epidural Narcotics
  • The Pediatric Medication list is much longer

37
Documentation of a Medication Not Given
  • A medication not given at the scheduled time is
    circled, initialed, and the corresponding code
    number is entered
  • example
  • hospital code 1 refused
  • hospital code 2 NPO

2
CK
38
Discontinued Medication
  • Draw a line through the discontinued medication
    and write discontinued (d/c) with date, time and
    initial in the stop column
  • Fax/scan the order to Pharmacy
  • all orders for medication time, dose or route
    changes should also be faxed/scanned
  • all orders to cancel a procedure should also be
    faxed if the procedure had an associated
    medication

________ ________________________
D/C CK
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40
Medications on Hold
  • Write Hold on CMAR
  • Remind the provider when placing an order on hold
    that we need a restart date and time
  • If a medication is ordered to be held without a
    restart date/time, it will drop off the CMAR and
    a new order is needed if it is to be continued

HOLD
41
Order Entry Error
  • If a medication appears in error on the CMAR,
    besides lining it out , please, write ERROR. We
    have to distinguish between errors and
    discontinued meds

_________ ERROR
42
Narcotics, Sedatives, and Antibiotics Renewal
  • Review STOP and START dates and times on CMAR for
    all narcotics, sedatives, and antibiotics
  • Narcotics and sedatives expire in 7 days
  • Antibiotics expire based on order (e.g. 1, 3, 7
    days)
  • Narcotics, Sedatives, and Antibiotics will fall
    off the CMAR unless there is a renewal order
  • Communicate with the provider to renew orders as
    appropriate

Narcotics Sedatives, and Antibiotics
43
IV Fluids
IVF
  • ALL IVF will appear on the CMAR
  • all IVF are scanned to Pharmacy
  • Pharmacy will enter any IVF into PharmNet
    regardless of whether the order appears in the
    left or right column of the order sheet
  • nurses will initial on the CMAR only when a new
    bag is initiated (spiked)
  • continue to record IO on the flowsheet
  • Flushes for central and peripheral lines will
    not appear printed on the CMAR until the protocol
    has been developed

44
TPN/Lipids
TPN and Lipids
  • Fax/scan all orders to Pharmacy
  • Document the time the bag is hung on the CMAR
  • Two nurses must verify contents of the bag with
    the order and initial in the initial column
  • Continue to record IO on the flowsheet

45
Sliding Scale Insulin
SSI
  • The sliding scale doses will be hand transcribed
    on the Insulin Sliding Scale MAR
  • this separate MAR will be used to prevent the
    need for daily transcription

46
Single Dose Orders
Single Dose
  • All single dose orders are hand transcribed onto
    the single dose section of the prn CMAR
  • The medication will appear on the next printed
    prn CMAR but will state that no dose is due

All single dose orders are hand transcribed onto
the single dose section of the prn CMAR
47
Printer Details
  • The CMAR will be batch printed on the patient
    care units daily at 0100
  • our current MAR is used for 5 days, not daily
  • manual print function will not be available on
    the units
  • call the HELP desk for printer problems
  • in the event of downtime, the CMAR will be
    printed when the system comes back up

48
Downtime
Downtime
  • In the event that the CMAR cannot be generated
    for the next day, the previous days CMAR will be
    used for up to 24 hours
  • the nurse writes the date/time/initials next to
    the medication administered
  • New medication orders can be transcribed on the
    next available space of the CMAR or a blank CMAR
  • this requires a Nurse verification

49
Downtime Rewrites
  • If there is not enough space to sign off
    medications (example Q4h doses), the medication
    can be rewritten in the next available space or
    blank MAR.
  • the nurse adds rewrite and date and draws a
    line through the medication that is being
    rewritten
  • the recopier must initial the recopied
    medication. If the recopier is an AA then the
    nurse must also verify accuracy by signing
    initials, date and time

50
Down Time Process
Unscheduled Downtime - unable to print MAR for
next day
If CMAR does not print, the previous days CMAR
will be used (for a maximum of 24 hours)
Follow transcription process for new orders on
existing patient or new Admission/transfer orders
Documentation after administration,nurse writes
date/time/initials next to the previous days
documentation
If space is limited, the Nurse can transcribe the
same med information in the next available space
or on a blank MAR. Nurse must add rewrite and
date in the original medication space and draw a
line through the med that is being rewritten.
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54
Support and Help
  • ERC Educators and Nurses from OE Department will
    provide support during the period of January 15
    (midnight) - January 20

55
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