Medication Documentation for Medication Assistants

This course prepares medication assistants in assisted living and long-term care settings to document medication administration accurately and defensibly using the Medication Administration Record (MAR). Learners will explore the legal and safety responsibilities associated with complete documentation and practice using correct, objective language when recording medications that are administered, refused, or withheld. Scenario-based exercises guide learners through morning and afternoon patient visits, providing hands-on MAR entry practice grounded in real-world situations.

Course Objectives
1. Explain medication documentation as a legal and safety responsibility, and use accurate, objective, and defensible language when recording medication administration.
2. Complete a Medication Administration Record (MAR) entry with all required fields, documenting immediately after administration.
3. Document refusals, PRN instances, and care plan discrepancies using objective language, and identify when verbal notification to the nurse is also required.

This course was written in alignment with the CMS Conditions of Participation for Long-Term Care Facilities: 42 CFR §483.45 (Pharmacy Services) requirements relevant to medication administration and documentation standards in skilled nursing and assisted living settings (including the accurate recording of medications administered, refused, or withheld):

• https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.45

Estimated Runtime: 15 minutes

Reviewed and approved by
Kim Tate, RN, BSN

NOTE: This course is not a substitute for legal advice for any individual provider or situation. Always consult your company’s legal or compliance personnel with any questions or concerns related to this subject matter.