A Practical Guide on How to document on a paper mar?

October 13, 2025 •

3 min read

Medication errors harm at least 1.5 million people annually in the U.S. alone. For healthcare professionals, mastering how to document on a paper mar? is not just a procedural step but a critical component of ensuring patient safety and legal compliance.

Quick Summary

This guide provides a detailed overview of the process for accurate paper Medication Administration Record (MAR) documentation, covering transcription, administration, and error correction to ensure patient safety and compliance.

Key Points

Legal Requirement: Recognize the paper MAR as a legal document that demands accurate, legible, and timely documentation.
Document Immediately: Chart every medication dose immediately after administration at the point of care to prevent pre-charting errors.
Proper Error Correction: Correct mistakes by drawing a single, dated, and initialed line through the error, explaining the correction on the back.
PRN Details: Record not only the dose but also the reason for administering PRN medication and the patient's response.
Legible and Permanent Ink: Always use permanent black or blue ink and ensure all writing is clear to prevent misinterpretation.
Adhere to the 9 Rights: Use the '9 Rights' of medication administration as a checklist before documenting to ensure accuracy and patient safety.
Stay Updated: Immediately update the MAR for any new or discontinued medication orders and never copy from an old chart.

Understanding the Paper MAR as a Legal Document

The Medication Administration Record (MAR) is a legal document used to record all medications given to a patient. It is essential for communication among healthcare providers, preventing errors, and meeting legal standards. Accurate and timely documentation is crucial, as the principle "if it wasn't documented, it wasn't done" applies. All entries must be accurate and legible.

The Foundation: Patient Information and the 9 Rights

Before administering or documenting medication, verify correct patient information on the MAR, including name, date of birth, allergies, MRN, and provider. Adhering to the '9 Rights' is fundamental for safety:

Right Client: Confirm patient identity.
Right Medication: Verify medication name.
Right Time: Administer at the scheduled time.
Right Strength and Dose: Check dose matches prescription.
Right Route: Ensure correct administration route.
Right Reason: Confirm purpose of medication.
Right Position: Account for patient positioning.
Right Texture: Note special preparation instructions.
Right Documentation: Ensure accurate and timely recording.

Step-by-Step Guide to Documenting on the MAR

Transcribing Physician Orders

Transfer physician orders to the MAR accurately, including all medication details, start/stop dates, and your initials. Do not copy from old MARs.

Documenting Routine Medications

Document immediately after administration using permanent black or blue ink. Place your initials in the correct date and time box. Ensure your full signature is on the master log.

Handling PRN (As Needed) Medications

For PRN medications, document the reason for administration, the dose, and follow up by recording the medication's effectiveness.

Documenting Discontinued Medications

Mark discontinued medications by writing "DC" and the date next to the medication name. Draw a line through future administration boxes. Some facilities may use a highlighter.

Correcting Documentation Errors

Correct errors by drawing a single line through the mistake, initialing and dating it, and providing an explanation on the back of the MAR or in notes. Avoid scribbling or white-out.

Paper MAR vs. eMAR: A Comparison

Comparing paper MARs to electronic systems (eMARs):


Feature	Paper MAR	eMAR (Electronic MAR)
Accuracy	Prone to human error.	Reduces errors with automation and alerts.
Efficiency	Time-consuming.	Streamlines workflow and reporting.
Real-Time Data	Information can be outdated.	Provides real-time, synchronized records.
Compliance	Manual audit trails.	Automated audit trails and reports.
Cost	Low initial, higher ongoing costs.	Higher initial, lower long-term costs.
Security	Susceptible to breaches/loss.	Enhanced security and audit trails.

Best Practices for Maintaining Accuracy and Compliance

Timeliness: Document immediately after administering medication.
Clarity: Write legibly, using permanent ink.
No Blanks: Avoid leaving blank spaces.
Standard Abbreviations: Use only approved abbreviations.
Point-of-Care Documentation: Chart at the patient's bedside.
Controlled Substances: Note controlled substances according to facility policy.
Rotate Sites: Track injection or patch sites.

Conclusion: The Importance of Diligent Documentation

Accurate paper MAR documentation is vital for safe medication administration, serving as a record, communication tool, and legal safeguard. Following proper transcription, administration, and error correction procedures is crucial for patient safety and professional standards. While eMARs offer advantages, the principles of diligent documentation remain paramount. Further guidance can be found in official resources like the CQC.

Frequently Asked Questions

To correct an error on a paper MAR, draw a single, thin line through the mistaken entry. Initial and date the line, and then write an explanation on the back of the MAR or in a designated notes section, according to facility policy.

When documenting PRN (as needed) medication, you must record the reason for administration, the dose, and the patient's response to the medication. This observation is typically noted on the back of the MAR or in the notes.

Always use permanent black or blue ink for all entries on a paper MAR. The use of pencil or erasable ink is strictly prohibited because it is not a permanent record and can be altered.

No, pre-charting medications is a significant error and is not permitted. Documentation must be completed immediately after the medication has been administered and the patient has taken it.

If a patient refuses medication, initial the appropriate box on the MAR and circle the initials. Document the refusal, the reason (if known), and any follow-up actions taken on the back of the MAR.

For a discontinued medication, write 'DC' and the date next to the medication name. Draw a single line through any remaining administration boxes for the month to clearly indicate it is no longer being given.

Paper MARs are used in some facilities due to factors like cost, existing infrastructure, or the specific needs of a small operation. However, the industry trend is moving towards eMAR systems, which offer greater accuracy and efficiency.