65G-7.008. Documentation and Record Keeping

(1) MAP and licensed health care practitioner shall maintain an up-to-date MAR for each client requiring assistance with medication administration, except when the client is off-site. The MAP and licensed health care practitioner must document the administration of medication or supervision of self-administered medication immediately on the MAR. The MAP and licensed health care practitioner may utilize the Agency’s Medication Administration Record Form, APD Form 65G-7.008 A, effective April 2019, adopted and incorporated by reference herein, which may be obtained at http://www.flrules.org/Gateway/reference.asp?No=Ref-10601, or on an alternative MAR form that includes the following information:

(a) The client’s name;

(b) Any client food or medication allergies;

(c) The name of each medication prescribed for the client;

(d) The medication strength (e.g., 5mg/ tsp);

(e) The prescribing health care practitioner for each medication;

(f) The date that the medication was ordered and any date the medication was changed (including D/C date);

(g) Prescribed dosage for each medication;

(h) Scheduled time of administration for each medication;

(i) Prescribed route of administration for each medication;

(j) Prescribed instructions for crushing, mixing or diluting of specific medications, if applicable;

(k) The dates each medication was administered;

(l) The initials and signature of the MAP or licensed health care practitioner who administered or supervised the self-administration of medications;

(m) A record of any medication dosage refused or missed, documented by the MAP or licensed health care practitioner responsible for administering the scheduled dosage, by drawing a circle around the appropriate space on the MAR form and initialing it; and,

(n) The reasons for not administering a medication, annotated and initialed by the MAP or licensed health care practitioner in the comments section on the MAR form.

(2) If necessary, it is acceptable for more than one ‘back’ of the MAR to be attached to any MAR to allow for more entries and explanations.

(3) It is permissible for MAPs or licensed health care practitioners to use a MAR provided by a pharmacy or from an electronic system if that MAR collects and records the same information as the Agency MAR.

(4) Each client’s record must contain the following medication documentation, recorded in a manner that effectively communicates to the Agency Staff and other health care providers, and which must be readily available to the MAP or licensed health care practitioner and for Agency review upon request:

(a) Completed MAR forms;

(b) A list of potential side effects, adverse reactions, and drug interactions for each medication. The drug monograph provided by the pharmacy or an electronic health program is sufficient to meet this requirement;

(c) A record of drug counts for each controlled medication;

(d) Written determination by the client’s physician that the client requires assistance with the administration of his or her medications, utilizing Authorization for Medication Administration, as adopted in rule 65G-7.002, F.A.C.; and,

(e) The current Informed Consent form adopted in rule 65G-7.002, F.A.C., permitting a MAP to assist with the administration of medication.

(5) The MAP or his or her employer must maintain documentation that the MAP has completed an approved medication administration course and is currently validated as competent to assist with the administration of medication.

Rulemaking Authority 393.501, 393.506 FS. Law Implemented 393.506 FS. History–New 3-30-08, Amended 7-1-19.