How does a caregiver document a medication during a shift?

Medication administration is recorded on the visit's Medications tab as each dose is given during the shift, not only at the end of the shift; check-out asks about doses still open.

Quick answer1 min readUpdated for AveeCare
Short answer

When eMAR is turned on, a caregiver records each dose on the visit's Medications tab at the time they give it. The tab lists the doses due during the visit with Due now, Late or Upcoming, plus any as-needed (PRN) medications. Tap Record, choose Given, Refused, Held, Missed or Self-administered, check the time given and tap Save dose. At check-out, the Medications step asks only about doses due during the visit that are still open.

Step by step

  1. Start the visit in the AveeCare app.
  2. Open the Medications tab. On the Overview, the Medications due card opens it too.
  3. Tap Record next to the dose you are giving.
  4. Choose what happened. For Refused, Held or Missed, pick a reason.
  5. Check the time given. It starts at now; change it if you gave the dose a little earlier.
  6. If the dose is early or late for its time, say why. Enter any reading the medication asks for, such as pulse.
  7. Tap Save dose. It is on the client's MAR right away.

Good to know

  • Long shifts: record each dose when you give it. A 10-hour shift with an 8 AM and a 2 PM dose shows each at its own time on the MAR.
  • No Medications tab? eMAR may be off, the client may have no current medications, your permission group may not include Client medications and eMAR, or your agency records doses at check-out only. Ask your office.
  • Forgot to record one? Check-out lists every dose due during the visit that is still open, each with its own time given. You can also record on the tab for a while after the visit ends.
  • Recorded doses show who recorded them and when, and cannot be recorded a second time.
  • No signal? Save the dose anyway. It is kept on the phone and sent once when you reconnect.
  • Recorded the wrong outcome? Ask the office to correct it on the eMAR page. Entries are never deleted: the correction is saved with a reason and the original is kept.
  • A dose with no record alerts the office about two hours after it was due (your agency can change this).

Keep going

Record doses and print the MAR

Work the med pass, record PRN, refused, held and missed doses, witness controlled drugs, amend an entry and download the monthly MAR.

Set up eMAR and add medications

Turn on eMAR, choose your state’s scope-of-practice wording, set nurses’ license type, and add scheduled, PRN and controlled medications.

Caregiver clock-in / clock-out

Clock in/out with the early-clock-in window and on-screen confirmation.

Written by
Calvin Nesvig
Founding Partner, AveeCare

Builds AveeCare full-time. The AveeCare Help Center is written and maintained by the team that builds the product, so the steps in every article come from the same people who ship the features.

All help articlesNeed a person?