- The MOR. A medication observation record must be kept for each resident who receives assistance with medications. Medication observation records (MOR) must include:
- The name of the resident.
- Any known allergies the resident has.
- The name and telephone number of the resident’s health care provider.
- The name of each medication prescribed and its strength and directions for use.
- A record of each time the medication was taken.
- A record of any missed dosages, refusals o take medications as prescribed, or medication errors
NOTE: RECORD MEDICATION EACH TIME IT IS OFFERED.
2. Working with the Medication Observation Record. The MOR is your record of all the medications a resident is receiving assistance with and the verification that you have assisted a resident to take his/her medication.
- When you provide assistance to a resident, record it on the MOR immediately after providing assistance.
- If a resident refuses to take a medication, record the refusal code on MOR front, and explain why the resident refused the medication on the MOR back. Contact with the resident’s physician should also be noted.
- When a resident is hospitalized or out of the facility and does not receive assistance with medication, indicate this on the MOR. For example, write “H” in the box you would typically initial if the resident is hospitalized, or “O” if the resident is out of the facility. On the back of the MOR, keep a record of when the resident takes his/her medications out of the facility so this matches the chart.
- Record the reasons for missed dosages and medication errors on the back of the MOR. Any resulting actions should also be noted, (i.e. Contacting the health care provider and instructions given).
- When an order is changed, the original entry on the MOR should not be altered. Instead, the original order should be marked “discontinued” and the new order written in a new space.
- The order written on the MOR must match the prescription label exactly. If the label says Buspar 5mg take 2 tablets twice daily, the MOR cannot read differently.
- MOR’s should contain the signature and initials of each staff person who will be using the MOR.
- Abbreviation should not be used on the MOR.
- DO NOT begin to assist the next resident until the MOR is completed on the resident you are currently assisting, and that resident’s medication has been returned to the storage area.
