Keeping records

Care homes should keep records of all medicines that are taken by residents. A common type of record used in care homes is called the 'medicines administration record'. Records should include:

  • the person's name, date of birth and weight (if under 16¬†years or frail)

  • the names of the medicines being prescribed

  • the strength of the medicines and the amount of the medicine or dose

  • how the medicines should be taken or used and how often

  • other information that might be important, such as whether the medicine should be taken with, before or after food

  • whether any medicines need to be monitored and when they should be reviewed

  • any support needed to help the person continue to take their medicines

  • information about any allergies to medicines or their ingredients or reasons why the person has been unable to take any medicines in the past.

Care homes should make sure the information in these records is accurate and up-to-date. They may need help from health professionals prescribing the medicines and the pharmacies supplying the medicines.

Records must be filled in as soon as possible after a person takes their medicine, including the date and time the medicine is taken.

The care home must keep these records safe, and destroy them when they are no longer needed.

If a person has any side effects to a medicine they are taking, or any are suspected, staff in the care home should record details of these in the person's care plan and should tell the person who prescribed the medicine or another health professional (usually the GP or an out-of-hours service) as soon as possible. They should also let the pharmacy who supplied the medicines know if the person agrees to this.