Electronic Medication Administration Records (eMAR) have become a standard tool in the UK healthcare settings. They offer a digital method of recording, tracking, and managing medication administration. While the eMAR system brings greater accuracy, transparency, and efficiency, it also imposes clear legal responsibilities on healthcare professionals.
Staff who use eMAR systems must follow strict legal and professional guidelines. These responsibilities exist to protect patient safety, uphold professional integrity, and ensure compliance with regulatory frameworks. Failure to meet these obligations can result in serious consequences, both for patients and the individuals involved.
Here, we share the key legal responsibilities that healthcare staff must understand and uphold when using eMAR charts.
- Accurate Documentation of Medication Administration
Staff must record every instance of medication administration with full accuracy. Each entry must include the medication name, dosage, administration time, and any relevant observations. Errors such as missed doses, incorrect timing, or wrong medication must be documented clearly and without delay. Full transparency is essential. If a mistake occurs, the system must reflect what happened and the reason for it. Staff must also log any changes to a patient’s medication immediately to maintain continuity and accuracy of documentation in care.
2. Verification and Patient Consent
Before administering medication, staff must ensure the prescribed drug matches the patient’s medical records. This verification helps prevent errors and ensures consistency in treatment. When introducing a new medication or altering a treatment plan, staff must obtain informed consent from the patient. This consent must be recorded in the eMAR system. Proper documentation confirms the patient has received sufficient information and agreed to the treatment, offering legal protection to the healthcare provider.
3. Safeguarding Patient Confidentiality
Protecting patient confidentiality remains a core legal duty. Use of eMAR systems must comply with the General Data Protection Regulation (GDPR). Only authorised personnel should access patient data, and all records must remain securely stored.
Staff must log in securely and avoid leaving the system open or unattended. Access to patient records must remain restricted to approved individuals. Adhering to these protocols ensures both privacy and compliance with legal standards.
4. Medication Errors and Incident Reporting
When medication errors or near misses occur, staff must report them immediately through the eMAR system. The system should capture details of the incident, the potential consequences, and the actions taken to resolve it.
Staff must follow NHS guidelines for incident reporting. Recording these events supports transparency and improvement in care, while also providing legal safeguards. All corrective actions must be documented in the system to establish a complete and traceable record.
5. Auditing and Accountability
Staff must carry out regular audits of eMAR entries to detect any discrepancies or incomplete records. This process helps maintain high standards of accuracy.
Every action in the eMAR system is logged, making it possible to trace all changes. Staff must ensure records remain complete and current. By conducting audits, healthcare professionals uphold accountability and reduce legal risk.
6. Clinical Decision-making and Documentation
All clinical decisions related to medication must appear in the eMAR system. If a medication regimen is adjusted, staff must record both the change and the reason for it.
This documentation ensures transparency and allows other healthcare providers to understand the rationale for treatment decisions. A well-documented record also provides legal protection if questions arise regarding the care provided.
Healthcare professionals must meet the requirements set by regulatory bodies such as the Care Quality Commission (CQC) and the Nursing and Midwifery Council (NMC). Proper use of the eMAR system supports this by maintaining accurate, up-to-date medication records.
Staff must remain aware of the regulatory standards that apply to their practice. By ensuring correct use of the eMAR system, they can demonstrate compliance during inspections or audits.
