CMT Documentation and Reporting 3 — Questions and Answers
Question 1: What is the primary legal purpose of the Medication Administration Record (MAR)?
- To provide a legal record proving what medications were given, when, and by whom (Correct answer)
- To help the pharmacy reorder medications automatically
- To track the resident's vital signs alongside medications
- To serve as the physician's original medication orders
Correct answer: To provide a legal record proving what medications were given, when, and by whom
The MAR is a legal document that verifies medication administration and can be used in legal or regulatory proceedings.
Question 2: A supervising nurse asks the medication technician to sign the MAR for a medication the nurse administered. What should the technician do?
- Refuse, because signing for something you did not do is falsification (Correct answer)
- Sign it to help the nurse save time
- Sign it and add a note that the nurse gave it
- Ask a coworker to sign instead
Correct answer: Refuse, because signing for something you did not do is falsification
Signing for a medication you did not administer is considered falsification of a medical record, which is illegal and grounds for termination.
Question 3: When must a medication technician document medication administration on the MAR?
- Immediately after giving the medication, before moving to the next resident (Correct answer)
- At the end of the medication pass for the entire shift
- Within one hour of completing the full medication round
- Before the next shift change, anytime during the shift
Correct answer: Immediately after giving the medication, before moving to the next resident
Documentation should occur immediately after administration to prevent errors such as double-dosing or missed doses.
Question 4: Which of the following changes in a resident's condition MUST be reported and documented by a medication technician?
- New rash appearing shortly after medication administration (Correct answer)
- The resident asking for an extra blanket
- A visitor arriving during medication pass
- The resident preferring a different juice with their pills
Correct answer: New rash appearing shortly after medication administration
A new rash after medication administration is a potential adverse reaction that must be reported to the nurse and documented immediately.
Question 5: What information is NOT typically required on a medication administration entry in the MAR?
- The medication technician's personal home address (Correct answer)
- Time of administration
- Initials or signature of the person who gave the medication
- Site of administration for injectable or topical medications
Correct answer: The medication technician's personal home address
Personal home addresses are never part of clinical documentation; only professional identifiers like initials or staff ID are used.
Question 6: A resident's family member asks to see the MAR to check what medications were given today. What should the medication technician do?
- Explain that medical records requests must go through the appropriate facility process (Correct answer)
- Show the family member the MAR immediately as a courtesy
- Deny the request because family members have no rights to records
- Photocopy the MAR and give it to the family member
Correct answer: Explain that medical records requests must go through the appropriate facility process
Medical records, including MARs, must be released through proper HIPAA-compliant processes, not informally handed over.
Question 7: Which section of the MAR typically records the reason a scheduled medication was NOT administered?
- The exception or reason codes section, often referenced with a circled entry or code (Correct answer)
- The pharmacy reorder section
- The physician signature block
- The allergy section at the top of the MAR
Correct answer: The exception or reason codes section, often referenced with a circled entry or code
MARs use exception codes (e.g., R for refused, H for hold) in a dedicated area to explain unadministered doses without erasing the scheduled entry.
CMT Documentation and Reporting 3
What is the primary legal purpose of the Medication Administration Record (MAR)?