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

Use correction fluid to cover the incorrect initials and leave the box blank.

Answer

Completely black out the initials with a pen and write 'Refused' next to it.

Answer

Ask the next shift's QMAP to witness and co-sign the correction.

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

Documenting the resident's vital signs before and after administration.

Answer

Getting a verbal confirmation from the resident's family.

Answer

Waiting to document until the end of the shift to see if it was effective.

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

Completely remove the medication from the MAR for the following month.

Answer

Cross out the medication with a thick black marker.

Answer

Leave the medication on the MAR but do not initial the boxes.

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

The QMAP who prepared the medication can have another QMAP document its administration.

Answer

Documentation should be completed at the end of the shift to ensure accuracy.

Answer

Use a pencil so that any mistakes can be easily erased and corrected.

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

Insist the resident take the medication as it is prescribed by the doctor.

Answer

Hide the medication in their food to ensure they receive it.

Answer

Leave the medication on their nightstand for them to take later.

Question 6

When transcribing a new medication order onto the MAR, what is the primary source a QMAP must use?

Accepted Answer

The written physician's order.

Answer

The previous month's MAR.

Answer

The pharmacy label on the medication bottle.

Answer

Verbal instructions from the facility nurse.