NAME OF SERVICE OR ESTABLISHMENT:____________________________
NB This template is deigned to shape the written procedure for the administration
of medication in individual establishments and will therefore be different for each
service. However, all of the points below must be covered in each service policy
and the manager concerned must refer back to the generic Departmental
Medication Policy to ensure that the service policy complies with it. Local service
procedures must be reviewed annually or more often if changes to practice
1) State the CSI standards to which your service is working (delete as
Domiciliary (day services to follow these standards)
2) State the method of administration used in your services
Monitored Dosage System (blister packs)
State your procedure for administering medication, to include the following where
Who administers medication – which grades of staff, how many, where in
Any special arrangements – e.g. wear a tabard/take off bleep
Medicines not to be left unattended
Give at correct time (and any leeway allowed)
Stay with client until taken
Do not give to a third party to administer
Sign only after safely taken
Make sure there are no gaps left on chart
Report any concerns or anomalies to…(who)...and record…(where)…
Report any medication errors – near miss/SOVA/internal recording
All of these points should be checked during administration.
State if your service administers PRN medication.
State your procedure for PRN medication to include the following where
Where recorded e.g. care plan, support plan, medication agreement.
Instructions for PRN medication should list exact circumstances when
drug should be given with evidence e.g. GP letter, Consultant’s report
Times and dose of administration of PRN medicines should be recorded.
State where else administration of PRN medication should be recorded
e.g. daily notes, individual file, handover sheet.
State the procedure for administering controlled drugs, to include:
Who can do this
Where the drugs are stored
How keys are assigned, handed over and accounted for
How to count and record controlled drugs
How to record and report any concerns or anomalies eg near
miss/SOVA/manager on call.
1) State the records kept at your service in respect of medication, as appropriate
from the list below
Medication Administration Record (MAR) sheet
COSHH data sheets
Capacity Assessment for self-medication, refusal of medication etc.
Entry on individual care/support plan
Signed records of receipt/disposal of medicines
Photo of service user
Level of assistance required by service user (CSCI 3 levels)
2) The following information must be recorded in respect of each individuals
Name and age of resident/client including any nickname
Month and year
Name and strength of medicine
Route of administration
The frequency and time of administration of each dose
The commencement date of prescribing if known
Any special information, e.g. Before food, when required
Any known drug hypersensitivity (in red)
Indication that the dose has been administered and by whom
Indication that a new container has been opened.
GP name and address
Any other information relevant to the service.
Codes should also be listed to record non-administration of medication, as
T = Tracked – this code can only be used by someone in a management role and
is used to record that medication had not been signed for at the
time of administration but has been proven, on investigation, to
have been given.
R = Refused
A = Absent
S = Sleeping
F = Administered by Family
L = Leave (can also be used for short trips out)
O = Other – if this code is used a note must be made on the MAR chart
specifying the reason why the medication was not given.
SERVICE USERS GOING OUT
State how to record medication taken out ie as ‘leave’.
State how medication is accounted for and handed over when going out.
State where drugs are stored e.g. trolley in locked room, service users room etc.
State where to store drugs that need to be refrigerated.
State where to store controlled drugs.
State who can hold keys for drug cabinets and how these are assigned, handed
over and accounted for
RECEIPT/DISPOSAL OF MEDICATION
State if your service is responsible for checking the receipt of medication
State what to check when receiving medication into the service as appropriate:
1. Name and strength of medication
2. Name of person medication has been prescribed for
3. Dose and frequency
4. Date the medicine was dispensed
5. Quantity dispensed.
6. Name and address of dispensing pharmacy
State how this is recorded and who/how many people sign for this.
State the special arrangements in respect of controlled drugs
State how medicines should be disposed of and how to record this.
State if your service administers non prescription medication.
State what records are needed:
Agreement from pharmacist
Entry on support plan
State procedure in your service to administer non-prescription drugs.
State how you check whether medicines are appropriate for this person e.g.
interactions, allergies, contra-indications.
State how medication errors/anomalies/concerns should be recorded e.g.
Near miss forms – must be done
SOVA AP1 form – must be done
State who is to be notified of any error or anomaly e.g. on call senior, unit
manager, next of kin.
State who to contact for advice in the event of overdose/under or missed dose,
medication given to wrong person, e.g. NHS Direct, GP, Pharmacist.
State the audit/monitoring systems for medication in the establishment e.g. who
monitors, how often, how is this recorded, who is this reported to?
STAFF GUIDE FOR THE ADMINISTRATION OF MEDICATION
(to be read in conjunction with Luton Borough Council policy and
procedures for your work area / setting)
Administration & Recording
Check that the medication you are administering is clearly labelled with
the clients name, medication name, date prescribed or expiry date, dose,
frequency, and date opened.
Check these details against the MAR chart or prescription.
Refer to care plan or information on the MAR chart to confirm route of
Sign the MAR chart once the medication has been administered.
Charts must indicate if the client was absent or refused medication.
This should be a pharmacists printed label (unless it’s a home remedy/
bought over the counter).
Do not administer medication if the label has been tampered with or is
missing. Seek advice from the prescribing doctor or dispensing pharmacist
Do not administer medication unless you have been part of the process of
checking MAR charts and preparing the dose to be administered
Report to manager and complete a near miss form and other forms
appropriate to your work area e.g. SOVA, Cause for Concern under Care
Homes Regulation 37.
Do not give medication to anyone else, other than the person it has been
Do not administer a different dose than what has been prescribed unless
there is written authorisation from the prescribing doctor or nurse
Do not give invasive treatment e.g rectal diazepam, gastrostomy,
injections etc, unless you have been trained to do so
Do report any incidents e.g. overdose, missed dose etc to your manager
and record these incidents on the appropriate record.
Do not leave medication laying around, ensure it is securely stored
Advice on any aspect of the administration of medication or on any other
medication issues is available from the pharmacist, GP, Advanced
Practice nurse or Community Nurse.