Chart: Med Log Tab (MAR)

The Med Log tab allows users to complete standardized assessments like vitals and observe or administer medications that have been ordered or prescribed to the patient on a daily basis. You can also administer PRN medications, as needed. If your organization uses the Inventory feature, you can adjust inventory directly from this page. 

Note: The name of this tab is customizable under Patient Processes. 

Note on Types

eRx orders created in Rcopia or in the EMR will appear as eRx in the Type column, while the other types will be listed as Taper eRx, Titration eRx, or PRN eRx. Non eRx orders will appear as MED.

Observed vs. Administered

Medication and Action orders will be marked as Observed or Administered based on your user role and the Observation Status setting which can be set in your Instance settings and/or individual locations (in a master instance).

• Mark MARs observed/administered based on roles: Doctors and Nurses will document as administered, and Techs will document as observed.
• Mark all MARs as observed: All roles will document as observed.
• Mark all MARs as administered: All roles will appear as administered.
• Mark all MARs as patient reported: All roles will document as patient reported to [user documenting].

Note on MARs After Discharge

When a patient is discharged, active doctor’s orders are not automatically stopped, but the MAR will no longer generate new entries.

Integrated Assessments

Required Roles: Integrated Assessments can only be logged by Super Admins, Record Admins, Doctors, Nurses, and Techs.

From the Med Log, you can document key integrated assessments including:

Vitals Glucose Height and Weight Orthostatic Vitals

CIWA-AR CIWA-B COWs

Not seeing an assessment in your environment? Check out this article for help setting up integrated assessments. 

Med Log Navigation

1. ← Med Log: Displays a full history of all medications or actions logged for this patient from the Med Log tab.
2. ← Med Pass: Opens Dashboard > Med Pass.
3. Use the Calendar to switch between current, past, and future med logs using the arrows next to the date, or click on the date to see the Med Log for a specific date.

Actions and Medications

Both standard and PRN medications appear and can be acted upon here.

Standard

Standard Action and Medication orders appear in the following sections.

• Actions: The scheduled action orders that the provider chose to show in the Med Log. 
• Medications: The patient's medical orders (standard or PRN) with scheduled frequencies (e.g. 3 times a day, at a specific time) and regular medical orders with interval frequencies (e.g. every 8 hours, every 2 days). The Type column helps to identify if the medication is PRN or not.
• Quantity: If the medication order has a variable dose, you will be able to choose which quantity is being administered here.
• Maximum Daily Dose: If a medication order includes a maximum daily dose amount, you will be able to administer that medication until the amount is reached, at which point, you will see the following flag in the Quantity field and be unable to dispense anymore of that medication to the patient that day.

If the substance is controlled, there will be a controlled substance label.

• C-I: These drugs have a high potential for abuse. No medical uses for treatment.
• C-II: High potential for abuse. Has accepted medical use for treatment.
• C-III: Less abuse potential than C-II drugs. Accepted medical use.
• C-IV: Less abuse potential than C-III drugs. Accepted medical use.
• C-V: Less abuse potential than C-IV drugs. Accepted medical use.

PRN Actions and Medication

PRN indicates the Medication or Action Orders occur on an as-needed basis. Action orders and Medications are marked as PRN on the order.

• PRN Actions contain all actions marked as PRN. Once observed/administered, the log will show up in the Scheduled Actions section (PRN type).
• PRN Medications lists PRN medication orders with interval frequencies (e.g. every 4 hours, every 7 days). Once observed/administered, the log will show up in the Scheduled Medications section (PRN type). Click here to learn more about PRN Medications. 

Dose/Log

Every dose/log is linked to a particular medication or action order. You can click on the Medication/Action title to open specific order details.

If the medication order included a maximum daily dose for the medication, it will appear here as well.

Managing Inventory

The inventory column is available for organizations using the Medication Inventory feature. You can manage inventory directly from the Med Log as needed. Click here to learn more. 

Observe/Administer Medications and Actions

Let's review the steps for administering or observing the medication or action order on the Med Log.

Note: Once medication/action is logged, it cannot be changed or deleted (not even by a Super Admin).

• Find your dose/log on the list of Medications or Actions. Scheduled medications and actions can be sorted by each column as well as searched by keywords from the title, time, type, or dose/strength, e.g., by Medication Name or PRN type.
• Select Yes or No under Occurred/Taken column for scheduled orders.
• If the order specified a quantity range, you will be able to indicate which quantity was administered.
• Add a Comment, this field is required when the Require MAR task Not Done comment instance setting is enabled. Otherwise, it's optional.
• Then click on Save Status to complete the log.
• For Medications, you'll have two additional options once the status is saved: 
  • Add Note: This option will place a note below the administered medication with the date/time and user who created the note.
  • Note Not Done: Use this option when a medication has been charted as administered/observed but was not in fact given. In the note, explain why the medication was not administered. The medication will remain on the MAR as given with a clear visual indication that the medication was not given.
• For PRN medications and actions, pick the time, modify the Reason if necessary, and click on Administered By/Observed By to complete the log.
  • For medications with an interval assigned, the next due time will display.
  • PRN Medications can be administered early if the PRN Medication Administration Interval setting is configured for the Instance or Location.
• If your facility requires a patient signature, click on the Patient Signature button next to the patient's picture and collect the signature.
  
• Tip: You can use full-screen mode to hide the patient's information and tabs from the patient. Click on Expand icon to enable the full-screen mode, and click on the Lock icon to lock it with your password.
  

You can log the patient's response to the medication (first and ongoing) if configured in your Instance or Location Settings. For a more detailed guide on first and ongoing responses, please check out this article.

Nurse Review

1. Orders pending Nurse Review will be grayed out in the Med Log tab until the review is completed.  
2. Only Nurse Reviewed orders will be available for administration in the MAR.