3.2 Identify the required information from prescriptions/medication administration record

This guide will help you answer 3.2 Identify the required information from prescriptions/medication administration record.

When working in health and social care, handling medicines safely matters. Everyone involved must know how to read and understand prescriptions and medication administration records. These documents guide safe medicine use and help avoid errors. Knowing what to look for protects the people receiving care, supports your legal duties, and keeps you and your colleagues safe.

This guide covers the key information you must identify in both prescriptions and medication administration records.

What Is a Prescription?

A prescription is a legal document written by a healthcare professional, such as a doctor, nurse prescriber, or pharmacist. It tells exactly which medicine to give, in what amount, and how often. Only certain professionals can write prescriptions. Prescriptions must follow the law and professional guidance.

Prescriptions may be either handwritten or printed. Some may be generated electronically. They are used in community settings, GP surgeries, hospitals, and sometimes in care homes. A correct prescription helps you provide the right medicine at the right time.

What Is a Medication Administration Record (MAR)?

A Medication Administration Record (MAR) is a document used by care staff and healthcare workers. It tracks what medicines are given, when, to whom, and by whom. Each person who receives medicines has a separate MAR.

The MAR may be on paper or kept electronically. Sometimes, it is known as a MAR chart or administration chart. The records are used in care homes, home care services, and other settings where staff give medicines on behalf of others.

Accurate MARs help track medicines and prevent mistakes.

Why Is the Information Important?

Incorrect information can lead to missed doses, overdoses, allergic reactions, or even hospital admission and death. Reading the documents properly avoids these risks.

The right information helps:

• Give the correct medicine
• To the right person
• At the right time
• In the right way
• With accurate records kept

Now I will break down the details to identify on both documents.

Key Information on a Prescription

Always check every piece of information before using a prescription to guide medicine use. Prescriptions will contain most or all of the following:

Person’s Details

• Name (full name)
• Date of birth
• Address

Check these match the service user. This prevents giving medicine to the wrong person.

Date of Prescription

This is the date the prescription was written. Some medicines are only valid for a short time after issue. The date helps check the prescription is still ‘in date’ and legal.

Details of the Medicine

• Name of the medicine (generic or brand name)
• Strength of the medicine (such as 5mg, 250mg)
• Form of the medicine (such as tablets, liquid, cream, injection)
• Quantity to be supplied (Number of tablets, volume of liquid, etc.)
• Dosage instructions (how much to give and how often)
• Route (how to give—for example, by mouth, on the skin, by injection)

Take time to read these carefully. Medicines come in different strengths and forms. Confusing them is a common cause of accidents.

Dose

• How much of the medicine the person should have each time

For example: “One 500mg tablet” or “5ml by mouth twice daily.”

Frequency or Timing

• When and how often the medicine should be given

For example: “Three times daily” or “Every morning at 8am.” Some medicines must be given at fixed times for safety.

Route of Administration

• How the medicine is to be administered

Examples:

• By mouth (oral)
• Injected (intramuscular, subcutaneous)
• On the skin (topical)

Never give a medicine by the wrong route. Some are dangerous if not given the right way.

Special Instructions

There may be additional instructions, such as:

• “Take with food”
• “Crush tablet and mix with water”
• “Avoid alcohol”
• “Monitor blood pressure before dose”
• “Discard after 28 days of opening”

Following these extra notes keeps people safe.

Prescriber’s Details

• Full name of the prescriber
• Signature (if paper prescription)
• Professional registration number
• Contact information

If you have questions, you can contact the prescriber directly. Only authorised people can prescribe in the UK.

Allergies or Sensitivities

Some prescriptions include details of known allergies or sensitivities. Never give a medicine if there is an allergy stated.

Prescription Number

Some prescriptions have a unique reference number. This can help when checking or tracking repeat prescriptions.

Legal Classification

For controlled drugs (such as morphine or methylphenidate), extra legal requirements apply. These are marked on the prescription.

Key Information on a Medication Administration Record (MAR)

A MAR is designed to document and track medicine use for each service user. It acts as a record for both staff and management. The MAR will often appear as a chart with columns and rows.

Look out for these details on every MAR:

Person’s Details

• Full name
• Date of birth
• Address or room number (in a care home)

Always check the name and details match the person you are caring for.

Details of Each Medicine

• Name of the medicine
• Strength
• Form (tablet, capsule, cream, liquid, etc.)
• Prescribed dose
• Route (such as oral, topical, inhalation)
• Frequency and time of administration

The MAR should clearly state these for each medicine a person is taking. If information is unclear or missing, speak to your supervisor.

Start Date and End Date

• When to begin giving the medicine
• When to stop (if a course is finished)

Some MARs have columns for each day, starting from the initial date. Always check for new or finished medicines.

Administration Times

• Scheduled times of day for each dose
• For example: 8am, 12 noon, 8pm

Some medicines must be spaced out evenly for safety.

Signature/Initials of Staff

• Box for the person giving the medicine to sign or initial after administration
• Shows who gave the medicine, so errors can be traced and safe practice checked

Sometimes, codes are used (such as ‘x’ or a letter) to show a dose was not given. These must be explained in the record elsewhere.

Missed Doses or Refusals

• Space to record when a dose is missed—why, and what action was taken
• Reasons could be “refused,” “on leave,” “unwell,” “not available”

Good MARs will have a key or guide showing how to record these events.

Allergies or Adverse Reactions

• Clearly record any allergies to medicines
• Reactions must be explained (for example, rash, sickness, breathing trouble)

Never give a medicine listed as an allergen on any record.

Other Instructions

• Extra safety notes, such as “monitor pulse before dose”
• Special storage information (like “keep in fridge”)

If a medicine must be stopped or a dose changed, it should be made clear on the MAR.

PRN (“When Required”) Medicines

Some medicines are only given when they are needed—for example, pain relief or inhalers. MARs record:

• Maximum allowed dose in 24 hours
• Time between doses
• Reason for administration
• Exact time and amount actually given each time

Always check the latest record before giving a PRN medicine.

Staff Guide and Coding System

A MAR will have a guide for staff, showing what each code or mark means. Always read this so you record medicine use the right way.

Weekly or Monthly Totals

Some MARs will record how much medicine was given each week or month. This helps with stock control and auditing.

Checking the Information

Before you give medicine, use a basic safety check every time.

Ask yourself:

• Do the name and date of birth match the service user?
• Is the medicine name, strength, and form what the prescription or MAR says?
• Does the dose agree with the written instructions?
• Is the timing correct?
• Am I using the right route?
• Are there any allergies or reactions on record?
• Have any doses been missed or refused?
• Is the medicine still in date and properly stored?
• Has anyone else recorded information for this dose?

If any information is missing or unclear, do not give the medicine until you have checked with your manager or the prescriber.

Risks if Information Is Missing or Wrong

Having incomplete or wrong information risks harm.

Examples:

• Giving a wrong medicine due to a similar name or look
• Under- or overdosing by missing the strength or dose
• Giving a medicine after the course should have ended
• Administering to the wrong person
• Not recording allergies and causing a reaction
• Missing a special instruction (such as “take with food”), leading to side effects

In the worst case, the person could become very ill or die. Even if the person seems fine, errors must always be reported.

Good Practice in Using Prescriptions and MARs

Take the following steps every time:

• Read every item carefully—do not guess or assume
• Match all details to the person before handling or giving a medicine
• Look out for changes or new instructions
• Ask about anything that is unclear, missing, or looks suspicious
• Record every administration immediately and sign your entry
• Store documents securely, following your workplace’s confidentiality policy

Never pre-sign for a dose. Never try to fix or rewrite a prescription or MAR yourself.

Where to Find Support and Guidance

If you are not sure:

• Check with your supervisor or line manager
• Speak to the pharmacist supplying the medicine
• Check your organisation’s medicine policy and procedures
• Use official guidance from NICE, the Royal Pharmaceutical Society, or Social Care Institute for Excellence (SCIE)

At all times, remember you have a duty to keep medication handling safe—both for yourself and service users.

Final Thoughts

Knowing which information to look for on prescriptions and MARs is a core part of safe practice. Gathering and checking every detail prevents accidents and builds trust among people receiving care and their families. Taking this responsibility seriously means you help protect every person you support and show professionalism in your work.

If you are ever in doubt, take time to look again or ask someone more senior. Making time for careful checking, clear record keeping, and asking questions keeps you, the team, and service users safe. Over time, you will become more comfortable with these documents, but never rush or assume. Safe medicine handling matters to everyone, every single day.