A medical administration record is a printed record of documentation that is used by nurses in nursing homes and other long term care facilities detailing the drugs administered to a resident. Writing a medical administration record has certain general principles and it should be:
- Legible
- Signed by the nurse administering the medication
- Accurate and precise detailing the medication administered to the resident
- Dated with the time of when the medicine was administered
- Free of abbreviations and any unnecessary jargon
As for the information typically included in a medical administration record, APL Med notes that it should include:
- Date and time of when medication was administered
- Initials or name of the medical staff transcribing the order
- Initials or name of the medical staff administering the medication to the resident
- Name of the medication
- Dosage of the medication
- Signature of the nurse immediately after the medication has been administered
To ensure safety during medication administration and when using a medical administration record, the Oregon Department of Human Services recommends that nurses and physicians should always remember the six rights and the three checks. The six rights refer to having the correct:
- Person
- Medication
- Dose
- Time
- Route and
- Documentation
As for the three checks, it refers to checking the:
- Name of the patient
- Strength and dosage
- Frequency of administration
The three checks and the six rights should be used by nurses when they are accepting an order, transcribing orders into a medical administration record, setting up and giving medications, and documenting in the medical administration record.
Due to the passing of the American Recovery and Reinvestment Act (ARRA) in 2009, which as noted by The Balance, allocated 17 billion dollars to modernize health information technology systems, long term care facilities have transitioned to the more modern eMAR (electronic medical administration record). This is due to its numerous advantages over paper records.
Advantages of eMAR nursing Software
There are several benefits of using eMAR nursing software. Nurses and nursing home administrators can expect to benefit from an electronic medical administration record in the following ways:
- Faster and more timely reports
- Accelerated processes and increased staff efficiency
- Fewer medication errors and missed dosages for residents in a long term care facility
- Better care for residents with updated records and faster data retrievals
- Decreased stress levels for nurses, as they can trust in the accuracy of their patient records
- Higher chance of warning nurses of potential drug interactions, preventing harm to the resident in the nursing home
- Improved communication between the long term care facility and the pharmacy, resulting in better care plan management and reducing the chances of wrong medication orders
- Regular real-time updates and supervision performed by leadership in a nursing home or SNF, enabling supervisors to check a resident’s care progress more efficiently, thus making documentation changes when needed
- Enhanced medication audits and improved inventory controls in the skilled nursing facility or nursing home.
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9 Easy Steps to Choosing the Best eMAR Software
We have talked about a medication administration record and we have also introduced its modern counterpart, the electronic medication administration record. In addition to that, we have mentioned several eMAR benefits to nursing homes, skilled nursing facilities, and other long term care providers. But how do nursing home administrators choose the best eMAR software for their facility? Medical Records recommends the following nine steps:
1. Create a List of Requirements
A nursing home has specific needs and requirements that differ from an assisted living facility. Hence, nursing home administrators should list all their facility requirements in their electronic medical administration record.
One of the easiest ways of creating a list of requirements is by asking the nurses and physicians who interact with residents on a daily basis. The primary users of the long term care software will understand what features they would want in an eMAR software. This means that one should let a physician take charge of creating the list of requirements, and not the administration staff.
2. Analyze the Facility’s Budget
The initial cost of purchasing eMAR software can be high. Therefore, facilities need to be mindful of hardware costs, implementation, training, and maintenance costs. Accounting staff should use the financials module in their long term care software to calculate if the cost of the eMAR software falls into the facility’s budget.
3. Consider Specialty-Specific eMAR Software
Using the previously created list of requirements, administrators should now proceed to look for software providers that cater to their specialty. Nursing home software providers design modules that meet the various needs of nursing homes and other long term care providers. These needs differ from those of a hospital, which is why it is important for long term care administrators to pursue eMAR that is specific to post-acute care.
4. Consider the System Architecture
Regarding system architecture, administrators should ask themselves if the software is web-based or client-server-based. However, it is worth noting that no architecture is better than the other. It simply depends on the requirements of the long term care facility. For example, if a nursing home does not have its own servers, it may be better to choose a web-based long term care EHR software system. If, however, the facility does have access to its own servers and would like to host its own resident data on its servers, then a client-server software system may be the better option. Some EHR vendors provide both options.
5. Ensure the Software Is HIPAA Compliant
Security is a major concern when using technology today. This is especially true in SNFs and nursing homes, where resident information must be kept private and secure from all but authorized nurses and physicians. HIPAA compliant eMAR software is software that has met all federal regulations safeguarding the protection of resident medical information. Therefore, nursing homes should research the long term care software in which they are interested beforehand and ensure that it is HIPAA compliant.
6. Get Feedback From Facility Staff
Once an administrator has found a long term care software system that seems appropriate for his or her facility, they should book a demo. The demo enables staff to familiarize themselves with the care plan software and its features. In addition, this enables the administrator to collect feedback from nurses and physicians to determine whether the long term care EHR software can meet their requirements.
7. Analyze the Customer Support
One should always check a software provider’s level of customer support. For instance, do they provide 24/7 customer support? Do they deliver on promises? Nurses and physicians in a nursing home should reach out to the long term care software provider—especially during the demo stage—and test their level of customer support.
8. Let the Facility Lawyers Review the Contract
Once a facility has decided on an eMAR software, the facility lawyers should review the contract. Long term care software contracts are usually valid for three to five years. Hence, the facility lawyer should clearly explain all of the legal bindings in the contract to the nursing home administrator. In addition, nursing homes should negotiate fair contracts that allow them to discontinue the care plan software should it fail to deliver on its claimed features.
9. Allocate Significant Time for Implementation and Training
This is where good customer care from a nursing home software provider can prove helpful. Installing the long term care software into the facility’s hardware infrastructure can be technical. Therefore, having an IT expert on hand can be beneficial. Once the software is fully-implemented, nurses and physicians need to familiarize themselves with it. The quickest way to get started is by taking advantage of free, online training modules.
Nursing Homes and Electronic Medical Administration Record Software
The electronic medical administration record is an integral part of the modern long term care facility. It is up to the administrators to choose the best long term care software for their facilities, ensuring that their facilities provide the best care for their residents. By following the above tips, nursing homes and other long term care facilities can be assured that they are making the best eMAR software selection for them and their residents.
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