QMAP Documentation and the MAR

Question 1

A QMAP discovers they initialed the 8:00 AM medication slot for a resident who actually refused the medication. What is the correct procedure to fix this documentation error on the MAR?

Accepted Answer

Draw a single line through the mistaken initials, date and initial the change, then document the refusal on the back of the MAR or in the notes section.

Answer

The proper procedure for correcting a documentation error on a MAR is to draw a single line through the error, initial and date the change. You must then add a note, typically on the back of the MAR or in a designated section, explaining the reason for the correction (e.g., resident refusal). Never use correction fluid or obliterate the original entry, as the MAR is a legal document.

Question 2

When a resident receives a PRN (as needed) medication for pain, which of the following documentation steps is required in addition to initialing the MAR?

Accepted Answer

Recording the time, dose, reason for administration, and the resident's response after a follow-up assessment.

Answer

For PRN medications, a QMAP must document not only that it was given but also the specific time, dose, and the reason for the administration. Crucially, the QMAP must also follow up with the resident (typically within 30-60 minutes) to assess the medication's effectiveness and document the resident's status or response.

Question 3

A physician provides a written order to discontinue a resident's blood pressure medication. How should the QMAP properly update the MAR?

Accepted Answer

Write 'DC' next to the medication name and highlight the discontinued medication name with a transparent yellow marker, then draw a line through the remaining date boxes for the month.

Answer

The correct procedure for documenting a discontinued medication is to write 'DC' (for discontinue) and the date, draw a single line through the name of the medication, and then draw a line through all the remaining administration time slots for that month. Highlighting the medication name in yellow is also a standard practice.

Question 4

Which statement is a fundamental rule for documenting on the Medication Administration Record (MAR)?

Accepted Answer

A QMAP must only document medications that they have personally administered or monitored.

Answer

A core principle of medication administration is that the person who administers the medication is the one who must document it. This ensures accountability and accuracy. Documentation must be done immediately after administration, not before or at the end of a shift, and always in black ink.

Question 5

A resident tells you, "I don't want to take that pill today." Which of the following is the correct first step for the QMAP to take?

Accepted Answer

Document on the MAR by initialing the box and circling the initials, then record the reason for refusal on the back or in the notes section.

Answer

Residents have the right to refuse medication. When a refusal occurs, the QMAP must document it correctly. The standard procedure is to initial the appropriate box on the MAR, circle the initials, and then write a detailed note on the back of the MAR or in the designated area explaining the refusal. The appropriate supervisor should also be notified per facility policy.

QMAP - Qualified Medication Administration Person Practice Test

QMAP - Qualified Medication Administration Person Practice Test

QMAP Documentation and the MAR