QMAP Documentation and the MAR 1 — Questions and Answers
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?
- Use correction fluid to cover the incorrect initials and leave the box blank.
- Completely black out the initials with a pen and write 'Refused' next to it.
- 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. (Correct answer)
- Ask the next shift's QMAP to witness and co-sign the correction.
Correct 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.
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?
- Documenting the resident's vital signs before and after administration.
- Getting a verbal confirmation from the resident's family.
- Waiting to document until the end of the shift to see if it was effective.
- Recording the time, dose, reason for administration, and the resident's response after a follow-up assessment. (Correct answer)
Correct answer: Recording the time, dose, reason for administration, and the resident's response after a follow-up assessment.
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?
- Completely remove the medication from the MAR for the following month.
- 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. (Correct answer)
- Cross out the medication with a thick black marker.
- Leave the medication on the MAR but do not initial the boxes.
Correct 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.
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)?
- The QMAP who prepared the medication can have another QMAP document its administration.
- Documentation should be completed at the end of the shift to ensure accuracy.
- Use a pencil so that any mistakes can be easily erased and corrected.
- A QMAP must only document medications that they have personally administered or monitored. (Correct answer)
Correct answer: A QMAP must only document medications that they have personally administered or monitored.
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?
- 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. (Correct answer)
- Insist the resident take the medication as it is prescribed by the doctor.
- Hide the medication in their food to ensure they receive it.
- Leave the medication on their nightstand for them to take later.
Correct 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.
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.
Question 6: When transcribing a new medication order onto the MAR, what is the primary source a QMAP must use?
- The previous month's MAR.
- The pharmacy label on the medication bottle.
- The written physician's order. (Correct answer)
- Verbal instructions from the facility nurse.
Correct answer: The written physician's order.
To ensure accuracy and prevent errors, a new medication must always be transcribed onto the MAR directly from the current, written physician's order. Copying from an old MAR or relying on other sources introduces a high risk of perpetuating a past error. QMAPs are not permitted to accept verbal or phone orders.
QMAP Documentation and the MAR 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?