Medicines administration records in adult social care

Good record keeping protects people receiving medicines support and their care workers.

Social care providers must maintain secure, accurate and up to date records about medicines for each person receiving medicines support. This is required under The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Medicines support is any support that enables a person to manage their medicines. In practical terms, this covers:

• reminding people to take their medicines
• helping people remove medicines from packaging
• administering some or all of a person’s medicines

Follow the principles of the ‘6Rs of safe medicines administration’ when you support people with medicines.

General principles

Paper based or electronic medicines administration records should:

• be legible
• be signed by the care home staff or care workers
• be clear and accurate
• have the correct date and time (either the exact time or the time of day the medicine was taken)
• be completed as soon as possible after the person has taken the medicine
• avoid jargon and abbreviations

Find out more about what good looks like for digital records in adult social care.

Home care

Care workers should make a record each time they provide medicines support. This must be for each individual medicine on every occasion in line with Regulation 17. The record should include the details as outlined by NICE.

There’s no standard format for a medicines record. You should keep a clear record of all support provided for each medicine. Include who administered the medicine and whether it was taken or declined.

A family member or carer may give medicines support that is usually provided by a care worker. Agree with the person and their family how and who will record this. For example, a family member might administer a ‘when required medicine’ outside the care workers visiting times.

When the person is fully managing their medicines themselves, the care plan should clearly state this. You do not need to record individual doses taken by the person.

NICE recommends that medicines records should include:

• the name of the person and their date of birth
• the name, formulation and strength of the medicine(s)
• how often or the time the medicine should be taken
• how the medicine is taken or used (route of administration)
• the name of the person’s GP practice
• any stop or review date
• any additional information, such as specific instructions for giving a medicine. For example, medicines to be taken with food (such as ibuprofen) or without food (such as some antibiotics).

You might administer medicines from a multi-compartment compliance aid (MCA). You must make sure care workers follow the principles of safe medicines administration. The care worker could record words such as ‘MCA given’ or ‘blister pack given’ on the medicines record. To do this there must be an accurate record of the individual medicines contained in the MCA. This should be dated and kept with the medicines record. This means that it is possible to identify which medicines have been taken in the past.

Home care services must also have clear processes for recording:

• any changes to a person’s medicines
• any medicines-related problems.

This helps to check the support provided for each medicine even if it was several months before. Find out more about medicines reconciliation (how to check you have the right medicines).

If the medicine changes mid-cycle, make a new entry to make it clear when the dose changed. How to make handwritten records and changes should be covered in the medicines policy. Only make handwritten changes if you are competent to do so. Find out more about training and competency for medicines optimisation in adult social care.

Care homes

Care home staff should keep medicines administration records up to date. If a person's medicines change, staff should update the record. Find out more about medicines reconciliation (how to check you have the right medicines).

Care home providers should ensure that medicines administration records (paper-based or electronic) include:

• the full name, date of birth and weight (where appropriate, for example, for a frail older person)
• the name, formulation and strength of the medicine(s)
• how the medicine is taken or used (route of administration)
• known allergies and reactions to medicines or their ingredients, and the type of reaction experienced. You may need to contact the person’s GP for this information
• when the medicine should be reviewed or monitored (as appropriate)
• any support the resident may need to carry on taking the medicine (adherence support). Find out more about multi-compartment compliance aids (MCAs) (in care homes)
• any special instructions about how the medicine should be taken (such as before, with or after food).

Find out more about records for ‘when required’ (PRN) medicines.

You should also add a cross-reference to the MAR when a medicine has a separate administration record. For example, 'see warfarin administration record'.

If a visiting health professional administers a medicine, you should keep a record of this on the MAR.

Care home providers should make sure that a new, handwritten medicines administration record is produced only in exceptional circumstances. It must be created by a member of care home staff with the training and skills for managing medicines. The new record should be checked for accuracy and signed by a second trained and skilled member of staff before it is first used.

Retaining records

Keep medicines administration records for at least 8 years after the person’s care ended at the service. After 8 years, review the records. If they are no longer needed, destroy them in line with local policies.

If you scan your records, complete any quality checks and destroy the original paper copies. Find out more about standards of scanned records in the Records Management Code of Practice for Health and Social Care.