Medication Administration Record (MAR)
Medication Administration Record (MAR)
|MO/YR: Start/Stop | |Facility Name: |
|Date | | |
|Medication | |Hour |
| |Start | |
| |Start | |
| |Start | |
| |Start | |
| |Start | |
|Diagnosis: |DIET (Special Instructions, e.g. Texture, Bite Size, Position, etc.) |Comments |
| Allergies: |Physician Name |A. Put initials in appropriate box when medication is given. |
| | |B. Circle initials when not given. |
| | |C. State reason for refusal / omission on back of form. |
| | |D. PRN Medications: Reason given and results must be noted on back of form. |
| | |E. Legend: S = School; H = Home visit; W = Work; P = Program. |
| |Phone Number | |
|NAME: |Record # |Date of Birth: |Sex: |
|VITAL SIGNS |1 |2 |
| Date | Hour |Initials |Medication |Reason | Result | | |
| | |
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