Medicines administration records in adult social care

Page last updated: 4 November 2025

General principles

Paper-based (ideally provided by the supplying pharmacist) or electronic medicines administration records should:

be legible, clear and accurate, with no jargon and abbreviations
be signed by the care home staff or care workers
record the correct date and time (either the exact time or the time of day the person took the medicine)
be completed as soon as possible after the person has taken the medicine
record both medicines taken and when a person has refused their medicine.

When recording if a person has refused to take medicine, remember:

A person with mental capacity has the right to refuse medicines, even if this decision appears ill-judged to staff or family members who are caring for them.
For a person with fluctuating capacity or who lacks capacity, follow the principles of the Mental Capacity Act.

If you assess that a person lacks the relevant capacity, use the best interest process to guide decisions.

Find out more about what good looks like for digital records in adult social care.

Homecare

Care workers should only provide medicines support that has been agreed and recorded in the care plan. They should record each time they provide medicines support, for both prescribed and over-the-counter medicines.

This must be for each individual medicine on every occasion in line with Regulation 17: Good governance. The record should include the details as outlined by NICE guidance and be accessible, and in line with the person's expectations for confidentiality.

There is no standard format for a medicines record, but you should keep a clear record of all support provided for each medicine, including:

who administered the medicine
whether the person took or declined it.

A family member or carer may give medicines support that a care worker would usually provide. When this happens, agree with the person and their family how and who will record this. For example, a family member might administer a ‘when required medicine’ outside the care worker’s visiting times.

When a visiting healthcare professional, such as a community nurse, may need to provide support to administer medicines, it should be agreed how this information will be accessible to carers and care workers to avoid duplicating the medicines given.

Self-administration

When the person manages their medicines themselves, their care plan should clearly state this. There should also be a risk assessment that should indicate how often this needs to be reviewed, based on their needs.

You do not need to record the individual doses the person takes.

Medicines records

NICE recommends that medicines records should include:

the person’s name and their date of birth
the name, formulation and strength of the medicine(s)
how often the person should take the medicine or what time they should take it
how the person takes or uses the medicine (route of administration)
the name of the person’s GP practice
any stop or review date
any additional information, such as:
- specific instructions for giving a medicine for example, whether to take with food (such as ibuprofen) or without food (such as some antibiotics)
- whether there are any known drug allergies.

Multi-compartment compliance aids

If you administer medicines from a multi-compartment compliance aid (MCA) you must make sure care workers follow the principles of safe medicines administration.

The care worker could record words such as ‘MCA given’ or ‘blister pack given’ on the medicines record. In this case, you must keep an accurate record of the individual medicines contained in the MCA. You should date and keep it with the medicines record. This makes it easier to identify which medicines the person has taken in the past.

Homecare services must also have clear processes for recording:

any changes to a person’s medicines, including who requested the change and when
any medicines-related problems.

This helps to check the support provided for each medicine even if it was several months before. Find out more about medicines reconciliation (how to check you have the right medicines).

If the medicine changes mid-cycle, make a new entry to make it clear when it changed. The medicines policy should cover how you should make handwritten records and changes. Only make handwritten changes if you are competent to do so.

Find out more about training and competency for medicines optimisation in adult social care.

Care homes

Care home staff should keep medicines administration records up to date. Staff should update the record if a person's medicines change or when they receive correspondence and messages about medicines.

Find out more about medicines reconciliation (how to check you have the right medicines).

You should ensure that medicines administration records (paper-based or electronic) include:

the person’s full name, date of birth and weight (where appropriate, for example, for a frail older person)
the name, formulation, strength and dose of the medicine(s)
how the person takes or uses the medicine (route of administration)
any known allergies and reactions the person has to medicines or their ingredients, and the type of reaction experienced. You may need to contact the person’s GP for this information
when to review or monitor the medicine (as appropriate)
any support the resident may need to continue taking the medicine (adherence support) or when a visiting healthcare professional, such as a community nurse, needs to provide administration support, such as administering an injection. Find out more about multi-compartment compliance aids (MCAs) (in care homes)
any special instructions about how the person should take the medicine (such as before, with or after food).

Find out more about records for ‘when required’ (PRN) medicines.

Other points to consider

Also add a cross reference to the MAR when a medicine has a separate administration record, for example 'see warfarin administration record'.

If a visiting health professional administers a medicine, you should keep a record of this on the MAR.

You should only produce a new, handwritten medicines administration record in exceptional circumstances.

A member of care home staff with the training and skills for managing medicines must create this record. A second trained and skilled member of staff should check the new record for accuracy and sign it before anyone uses it. Likewise, only people who are trained and assessed as competent should make and check any changes.

Retaining records

Keep medicines administration records for adults for at least 8 years after the person’s care ended at the service. After 8 years, review the records. If they are no longer needed, destroy them in line with local policies.

If you scan your records, complete any quality checks and destroy the original paper copies.

Find out more about standards of scanned records in the Records Management Code of Practice for Health and Social Care.