CMAR

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CMAR

• Computerized and Printed
• Medication Administration Record

CMAR
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Learning Objectives

• At the end of this module, the student will be
  able to
• 1.Discuss the differences between the current
  5-day MAR and the new pre-printed daily CMAR
• 2.Verify CMAR accuracy
• 3.Document medication administration or omission
  on the CMAR
• 4. Discuss the utilization of Kardex for
  non-medication orders
• 5. Explain how to complete and when to use
  variance form

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CMAR

• When January 23, 2006
• Where Housewide
• Who Nurses, AAs, RTs and Prescribers
• IS and Pharmacy are also involved

CMAR
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And Why?

• CMAR Benefits
• To optimize the medication administration process
  by utilizing standard administration times
• To reduce number of missing doses
• To enhance pharmacy-nursing collaboration
• To promote patient safety by improving accuracy
  of CMAR and reducing transcription errors
• To help us to prepare for EMAR and CPOE

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CMAR Basics

• The CMAR will cover administration from 0700 on
  the current day to 0659 on the following day (1
  day)
• Nurse completes variance report when the variance
  is noticed in the computer (real time)
• CMARs print on unit every day at 0100
• Nurse verifies the accuracy of the new CMAR after
  it prints at 0100
• When there is no space available on the CMAR,
  blank CMARs should be used
• Any orders or changes in orders after 2300 will
  be hand transcribed
• new medications should be hand transcribed onto
  the existing CMAR as well as on the next days
  CMAR

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CMAR Appearance

• There will be 2 CMARs for each
• patient routine meds and prn/stat meds
• both copies will be white
• CMAR will not be double-sided
• there will be a separate CMAR
• for sliding scale insulin
• The generic name will appear with the trade name
  in parenthesis
• Frequency and hours of administration will both
  be included
• standard medication times will be used
• antibiotic catch up grid will be used
• Approved substitutions will be provided for
  ordered meds

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CMAR Appearance (contd)

• You will see patient height, weight and allergy
  information included on the CMAR
• this information will be entered into Cerner by
  PCA (Ht/Wt) and Nurse (Allergy)
• if the patient has too many allergies, the CMAR
  will state Print kardex for the allergies. Be
  sure to print Kardex and place it in the med
  book, so it can be referred to by anyone
• Qualifying information (ex. Hold HRlt60) ordered
  by Prescribers will be included
• Automatic Stop dates will be pre-printed
• ex. prn Narcotics need to be re-ordered every 7
  days
• Administrative notes (directions) will be be
  displayed

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Example of CMAR (scheduled medication section)
CMAR will have more information for clinicians-
DOB, admitting dx, ht, wt, allergies
CMAR provides clinicians with approved
substitutions for ordered medications
CMAR provides additional information to the
clinicians about administration
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Example of CMAR (scheduled medication section)
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Example of CMAR-PRN medication section
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Example of CMAR-SSI medication section
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Administrative Notes

• Be sure to read all administrative notes
• Dosage A medication might appear that you do not
  think is ordered because it is added to another
  medication to make the dose ordered. For example
  a patient is ordered Percocet 10/325 1-2 tabs.
  Our pharmacy only carries the Percocet 5/325
  tabs. So in order to give the dose ordered
  (10mg/325), pharmacy adds oxycodone 5 mg. The
  administrative note indicates to give the two
  drugs together. Because they are two different
  drugs they are listed in separate boxes.

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Administrative Notes

• Dose Rounding A physician writes for lovenox 50
  mg. The dose printed on the CMAR is 60 mg. There
  is an administrative note stating per PT
  (Pharmacy and Therapeutics) policy the dose is
  rounded to 60 mg.
• Dose Description A physician writes for Percocet
  10/650. The dose printed on the CMAR is 2 tabs.
  There is an administrative note stating 2 tabs of
  5/325 10/650.

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Non-Pharmacy Tasks

• Non-pharmacy tasks will appear on kardex (e.g.
  dressing changes, tube flushes). Use flowsheet
• or another appropriate document for
  non-pharmacy tasks documentation.
• ! Do not document non-pharmacy tasks on
• CMAR.

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CMAR Workflow
Written MD Order
Nurse/AA scans order to pharmacy
Nurse reviews AA transcription
Nurse/AA transcribes order onto CMAR
Pharmacy verifies order and enters it into
PharmNet
New Pharmacy Order Notification appears on the
PAL
Nurse reviews order from Nurse Review
Any Variances
Meds sent to floor
No
Yes
Nurse does not apply Review to an order that is
questioned, completes variance form, and sends
original order to pharmacy
Nurse initials the written order sheet and CMAR.
Nurse apply Reviewin the Nurse Review tab
Nurse administers meds
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Nurse Review
Nurse verifies all of the new medication orders
in computer as the pharmacy enters them into
Cerner. The expected turnover time for pharmacy
order entry is 2 hours (from the time of scanning
till the time of med order appearance in the
Power Chart).

• Nurse Review Steps
• Open PAL
• Click on the eyesglasses icon to view the new med
  order only and then close the window
• Click on the Orders tab
• Click the Nurse Review sub-tab
• Select medication (s) order to be reviewed
• Review medication by comparing it to the written
  order
• Click Review button if the order is correct

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Medication Variance Form

• All printed medication discrepancies should be
  identified on the Medication Variance Form and
  corrected on the current CMAR (if appropriate).
• this includes changes to a medication order
  (dose, route, frequency or parameters), allergy
  information or patient weight
• allergy and weight changes should also be changed
  in Cerner
• the form should be scanned to pharmacy
• the variance will be corrected in the Pharmacy
  system

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Variance Form
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Medication Variance Form

• Nurse should leave the original variance form in
  the folder Variance above the fax/scan machine
  (after faxing/scanning)

Variance
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CMAR Workflow Night Shift
New CMAR prints at 0100
Nurse checks newly printed CMAR for accuracy b/t
0100 0400 by comparing it to the previous days
CMAR and the medication order (check dose,
frequency, times etc)
Present
Newly Printed
Any Variances
Yes
No
Nurse completes variance form and sends it to
pharmacy
Nurse initials the verification column init for
EACH medication
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Verification of Accuracy

• A nurse will check each newly printed CMAR for
  accuracy
• compare it to the previous days CMAR and the
  medication order (check dose, frequency, times
  etc)
• the nurse initials the verification column init
  for EACH medication
• a nurse verifies all patient information name,
  allergies, room number, and weight

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The Pharmacy Alert Notice

• The Pharmacy Alert Notice Form is still to be
  used when medications are missing from the
  patients medication drawer

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Filing of CMAR

• Newly printed CMAR is placed in the MAR binder by
  Nurse
• The CMAR from the previous day is folded in half
  and kept in the MAR binder
• Old CMARs (gt 24 hours) are filed in chronological
  order in the patients chart under the medication
  tab

Filing of CMAR
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Generic or Blank MARs

• Blank CMARs will be available on the unit
• scheduled and prn blank CMARs will
• be available on the unit
• blank MARs will be used for admission
  and transfer orders or when the
  printed CMAR is full and new medications are
  ordered
• a patient label is placed in the upper right
  corner
• allergy and weight are written in the appropriate
  place
• CMARs should be numbered if there is more than
  one (e.g., page 1 of 2)

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New Orders on an Existing Patient

• The medication is hand transcribed onto the
  current printed CMAR (or blank CMAR when current
  CMAR is full)
• Nurse verifies transcribed order with the
  prescribers order and initials the init box on
  the CMAR
• Fax/scan ALL orders to Pharmacy

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Transfers and Admissions

• Orders DO NOT need to be re-written
  when patients are transferred to
  another unit on the same service with the same
  level of care (ONT to Pulm ID)
• the same CMAR will be used until the new CMAR is
  generated for the next day
• enter transfer information into Medipac

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Transfers and Admissions

• Orders DO need to be re-written when patients are
  transferred to another unit with a different
  level of care (ICU to Pulm ID)
• new medication orders will be hand transcribed to
  a blank CMAR and this will be used until the next
  CMAR is generated
• all medications transcribed by an AA must be
  checked by a nurse (Nurse or LPN) however, all
  IV medications must be verified by a Nurse
• AA enters transfer information into Medipac and
  notifies Admitting

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New Admissions

• Admission orders are
• transcribed onto a blank CMAR
• Nurse verifies the transcription with the order
  and initials the initials column of the CMAR
• Orders are faxed/scanned to
• Pharmacy

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Medication Administration Times

• Medication administration times will be entered
  by Pharmacy and will appear on the CMAR
• in accordance with the newly (6/04) approved
  times listed in the hospital policy
• Peds, Psych, Rehab, and NICU do not follow the
  standard hospital dosing schedule
• example bid and q12 dosing times are now both
  1000 and 2200

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Medication Administration Times

• A prescriber order is required to change the
  standard administration time (the order should
  include the request for change and the new time
  of administration)
• the revised order will be faxed to
• Pharmacy and the time changes will
• appear on the next printed CMAR
• until the new CMAR prints, the nurse will draw a
  line through the standard time and write in the
  new time

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Documentation of a Medication Given

• Nurse or RCP initials on the line next to time
  after the medication is administered
• Nurse or RCP signs and dates in the signature
  section at the bottom
• The site of injection is entered after the
  initials using the assigned code number

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Documenting On/Off Times

• If drugs are ordered to start and stop at a
  certain time (ex. Nitrate Patch), the nurse will
  initial both events
• the administration time will print and the nurse
  initials that it was applied
• the off-time will be printed as a descriptor only
  and the nurse should hand document the off-time,
  initials and the word off

ON OFF
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Documentation for Unusual Dosing

• For medications due on odd days/every third day
  etc, the drug will appear daily but the
  administration time will only print on the day
  the the drug is to be given
• example Fentanyl Patch

Unusual Dosing
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Double Signature Requirements

• Two nurses must initial for any
• medications that require a double-check
• Reminder statements will be present for all Adult
  and Pediatric Medications that require a double
  signature
• Double Sign will be seen for all Adult and Peds
  medications that require a double signature
• For Peds- double sign will be seen for
  Pediatric medications only that require a double
  signature

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Double Signature Requirements

• Adult Medications
• Heparin IV
• Insulin
• Chemotherapy Drugs
• TPN/PPN/Lipids
• PCA/Epidural Narcotics
• The Pediatric Medication list is much longer

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Documentation of a Medication Not Given

• A medication not given at the scheduled time is
  circled, initialed, and the corresponding code
  number is entered
• example
• hospital code 1 refused
• hospital code 2 NPO

2
CK
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Discontinued Medication

• Draw a line through the discontinued medication
  and write discontinued (d/c) with date, time and
  initial in the stop column
• Fax/scan the order to Pharmacy
• all orders for medication time, dose or route
  changes should also be faxed/scanned
• all orders to cancel a procedure should also be
  faxed if the procedure had an associated
  medication

________ ________________________
D/C CK
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Medications on Hold

• Write Hold on CMAR
• Remind the provider when placing an order on hold
  that we need a restart date and time
• If a medication is ordered to be held without a
  restart date/time, it will drop off the CMAR and
  a new order is needed if it is to be continued

HOLD
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Order Entry Error

• If a medication appears in error on the CMAR,
  besides lining it out , please, write ERROR. We
  have to distinguish between errors and
  discontinued meds

_________ ERROR
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Narcotics, Sedatives, and Antibiotics Renewal

• Review STOP and START dates and times on CMAR for
  all narcotics, sedatives, and antibiotics
• Narcotics and sedatives expire in 7 days
• Antibiotics expire based on order (e.g. 1, 3, 7
  days)
• Narcotics, Sedatives, and Antibiotics will fall
  off the CMAR unless there is a renewal order
• Communicate with the provider to renew orders as
  appropriate

Narcotics Sedatives, and Antibiotics
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IV Fluids
IVF

• ALL IVF will appear on the CMAR
• all IVF are scanned to Pharmacy
• Pharmacy will enter any IVF into PharmNet
  regardless of whether the order appears in the
  left or right column of the order sheet
• nurses will initial on the CMAR only when a new
  bag is initiated (spiked)
• continue to record IO on the flowsheet
• Flushes for central and peripheral lines will
  not appear printed on the CMAR until the protocol
  has been developed

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TPN/Lipids
TPN and Lipids

• Fax/scan all orders to Pharmacy
• Document the time the bag is hung on the CMAR
• Two nurses must verify contents of the bag with
  the order and initial in the initial column
• Continue to record IO on the flowsheet

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Sliding Scale Insulin
SSI

• The sliding scale doses will be hand transcribed
  on the Insulin Sliding Scale MAR
• this separate MAR will be used to prevent the
  need for daily transcription

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Single Dose Orders
Single Dose

• All single dose orders are hand transcribed onto
  the single dose section of the prn CMAR
• The medication will appear on the next printed
  prn CMAR but will state that no dose is due

All single dose orders are hand transcribed onto
the single dose section of the prn CMAR
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Printer Details

• The CMAR will be batch printed on the patient
  care units daily at 0100
• our current MAR is used for 5 days, not daily
• manual print function will not be available on
  the units
• call the HELP desk for printer problems
• in the event of downtime, the CMAR will be
  printed when the system comes back up

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Downtime
Downtime

• In the event that the CMAR cannot be generated
  for the next day, the previous days CMAR will be
  used for up to 24 hours
• the nurse writes the date/time/initials next to
  the medication administered
• New medication orders can be transcribed on the
  next available space of the CMAR or a blank CMAR
• this requires a Nurse verification

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Downtime Rewrites

• If there is not enough space to sign off
  medications (example Q4h doses), the medication
  can be rewritten in the next available space or
  blank MAR.
• the nurse adds rewrite and date and draws a
  line through the medication that is being
  rewritten
• the recopier must initial the recopied
  medication. If the recopier is an AA then the
  nurse must also verify accuracy by signing
  initials, date and time

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Down Time Process
Unscheduled Downtime - unable to print MAR for
next day
If CMAR does not print, the previous days CMAR
will be used (for a maximum of 24 hours)
Follow transcription process for new orders on
existing patient or new Admission/transfer orders
Documentation after administration,nurse writes
date/time/initials next to the previous days
documentation
If space is limited, the Nurse can transcribe the
same med information in the next available space
or on a blank MAR. Nurse must add rewrite and
date in the original medication space and draw a
line through the med that is being rewritten.
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Support and Help

• ERC Educators and Nurses from OE Department will
  provide support during the period of January 15
  (midnight) - January 20

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