Medication Administration Records: What Your Notes Must Include

Why Medication Documentation Is Critical

Medication errors are consistently among the top three categories of Reportable Incidents to the NDIS Quality and Safeguards Commission. Proper documentation is not just about compliance — it's about participant safety.

The MARS Cross-Reference Requirement

Every medication administration must be cross-referenced against the participant's Medication Administration Record Sheet (MARS). The MARS is a legal document, and your progress notes must align with it exactly.

Before administering any medication:

Check the MARS for the correct medication name
Verify the correct dosage
Confirm the correct time
Check the correct route of administration
Verify the correct participant (yes, even if you know them)

This is known as the "5 Rights" of medication administration.

:::warning Administering medication without a current, signed MARS chart is a serious compliance breach. If the MARS is missing, expired, or unclear, do NOT administer and contact the supervisor immediately. :::

What to Record for Each Administration

Your documentation for every medication administration should include:

Required Fields

Date and exact time of administration (e.g., "0800hrs" not "morning")
Medication name (generic and/or brand name as listed on MARS)
Dosage administered (e.g., "500mg x 2 tablets")
Route (oral, topical, inhaled, sublingual, etc.)
Staff member name who administered
Second checker name (if required by organisational policy)
Participant's response — did they take it willingly? Any difficulty swallowing?

Post-Administration Monitoring

Observation period (typically 15-30 minutes)
Any adverse reactions or side effects
Participant's reported wellbeing after administration

Adverse Reaction Documentation

If a participant experiences an adverse reaction:

Document the exact time symptoms were first noticed
Describe symptoms objectively (e.g., "developed red rash on forearms within 20 minutes of administration")
Record vital signs if trained and equipment available
Document actions taken (e.g., "called 000," "contacted GP," "administered PRN adrenaline as per anaphylaxis plan")
Record all communications — who was called, when, what was advised

:::tip This is a Reportable Incident if it results in serious injury or hospitalisation. Ensure your documentation meets the 24-hour reporting standard. :::

Disposal Records

When medication is disposed of (expired, ceased, or unused):

Record the medication name and quantity disposed
Document the method of disposal (e.g., returned to pharmacy)
Record the date and two witness signatures
Note the reason for disposal

PRN (As-Needed) Medication

PRN medications require additional documentation:

Reason for administration — what symptoms prompted it?
Time of request or observation of symptoms
Effectiveness — did the medication work? Document follow-up at 30 and 60 minutes
Whether the prescriber's PRN parameters were met (e.g., "maximum 4 doses in 24 hours — this is dose 2")

Common Documentation Errors

Recording medications as "given" without specifying time
Not recording when a participant refuses medication
Forgetting to document PRN effectiveness follow-up
Using abbreviations not on the approved list
Not updating documentation when a medication is changed by the GP