eMAR vs paper MAR chart: what actually changes in a care home on the first day

On the first day of eMAR the medication round itself changes less than staff expect and the paperwork around it changes more. The senior still goes resident by resident with the trolley, still checks the person, the medicine and the dose, still watches it taken. What disappears is the hunt for a missing signature, the mental arithmetic on stock, and the monthly audit that finds the gaps three weeks too late. This guide compares the paper MAR chart with an electronic medication administration record round by round, sets out what stays the same, what goes wrong on day one, and how to prepare the week before so that the first round is uneventful.

The short answer

A MAR chart is the record of every medicine a resident is prescribed and every dose given, refused or omitted, with a signature and a code for each. An eMAR is the same record on a device, with the medicines list held electronically, each administration recorded by tapping, reasons required for anything not given, stock counted automatically, controlled drugs witnessed on screen, and every entry timestamped and attributed. The clinical practice does not change: the same checks, the same policy, the same consent, the same NICE guidance. What changes is that nothing can be left blank, PRN needs a reason and follow-up, gaps are visible to the manager the same hour, and the audit trail exists without anyone writing it. Day one goes well when the pharmacy record has been reconciled, every senior has been competency-checked on the device, and the wifi has been tested in the far corridor.

At a glance: the same round on paper and on eMAR

The table walks through the tasks of a medication round and shows how each is done with a paper MAR chart and with an eMAR system.

What a MAR chart is and what eMAR means

A medication administration record, the MAR chart, is the legal record of what medicines a person is prescribed and what was actually given. In a care home it is usually printed by the pharmacy each cycle, one sheet per resident, with a grid of days and times, and staff initial each box after administration or enter a code where a dose was not given. It sits alongside the controlled drug register, stock records, PRN protocols and the medicines policy.

eMAR stands for electronic medication administration record. It is the same record held in software on a tablet or phone, with the medicines list entered once from the pharmacy record or received electronically, administrations recorded by tapping, and reasons, stock, witnesses and timestamps captured as part of the act of recording. Searches for what is eMAR and mar vs emar usually come from seniors about to start using one, and the honest answer is that it is the MAR chart with the gaps designed out. Our guide to MAR chart codes explains the paper conventions that the eMAR replaces with reason lists.

The morning round on a paper MAR chart

Picture the 8am round on paper. The senior opens the MAR folder, finds the resident's sheet, reads the medicines, pops the doses, gives them, initials each box. If a medicine is not given, they write a code, and somewhere on the back they should write why. PRN is given if the resident asks and the senior judges it right, with the time written in. Stock is counted at the end of the cycle, or when something looks low. The controlled drug book is signed by two people. Creams are recorded on a separate chart that may or may not be in the same folder.

It works when everyone is careful. The problems are at the edges. A box left blank is found at the monthly audit. A PRN given at 3am is recorded but the reason is not. Stock runs out on a Friday because the count was wrong. A new agency senior cannot read the handwriting on a handwritten addition. A dose given late is initialled as if given on time. None of these is malice; they are what paper allows.

The morning round on eMAR

Now the same round on a device. The senior opens the round and the system shows the residents due medication in order. Each resident's screen shows the medicines due now, with a photograph of the person, allergies, and any instructions such as give with food or do not crush. The senior gives each medicine and taps to record it. If a dose is not given, the system asks for a reason from a list and a note. The next resident appears. When the round ends, the senior sees at a glance whether anything is outstanding.

The differences you feel on day one: nothing can be left blank by accident, because an unrecorded dose stays outstanding and is visible to the manager the same hour; PRN needs a reason and prompts the follow-up; stock counts itself and warns before the weekend; controlled drugs still need a witness, but the second person signs on the device and the balance is calculated; and time is stamped, so a late dose is visible as late. An eMAR built around rounds by resident makes the round feel familiar while removing the places where paper fails.

What stays exactly the same

The things that keep people safe do not change. The senior still checks the right person, the right medicine, the right dose, the right route, the right time, and watches the medicine taken. Consent is still sought and capacity still matters. Covert administration still needs a capacity assessment, a best interests decision and pharmacist advice. The medicines policy still applies, NICE guideline NG67 is still the reference, and the home is still responsible under Regulation 12 for managing medicines safely. Competency is still assessed by observation. The controlled drug cupboard, the register and the safe custody regulations are unchanged.

What eMAR changes is the recording, and it is worth saying that plainly to staff before go-live. Some seniors fear the device will make decisions for them. It will not. It will ask them to record the decisions they already make, in a way that cannot be skipped, and it will show the manager the result.

Nothing can be left blank

The single biggest change is that an unrecorded dose does not disappear. On paper, a blank box is invisible until someone reads the sheet. On eMAR, a dose that is due and not recorded stays on the round as outstanding, appears on the manager's dashboard, and if the system is set up that way, sends an alert after a set time. The senior cannot close the round with doses outstanding without recording a reason for each.

In the first week this produces a spike in recorded omissions that alarms managers, and it should not. The doses were always being missed; now they are being seen. Treat the first month's data as the true baseline, review each omission for its reason, and expect the number to fall as staff adjust. The homes that panic and switch off the prompts lose the point of the system.

PRN medicines: reasons, protocols and follow-up

PRN, as-required medicines, are where paper is weakest and eMAR strongest. On paper the time and dose are written; the reason, the resident's own request, and whether it worked are often missing, and the PRN protocol lives in a folder nobody opens. On eMAR the protocol for that resident and that medicine is shown at the point of administration: what it is for, the signs to look for, the maximum in 24 hours, the gap between doses, and what to try first. The senior records the reason, the system checks the timing against the last dose, and it prompts for an effectiveness check later.

This only works if protocols exist. Before go-live, write a PRN protocol for every as-required medicine for every resident, with the GP or pharmacist where needed, and enter them. Our guide to PRN medication protocols sets out what each should contain. Pain relief, laxatives, anxiolytics and medicines for distress in learning disability and mental health services are the ones inspectors follow most closely.

MAR chart codes versus reason lists

Paper MAR charts use codes for doses not given: refused, hospital, nausea, omitted by nurse, and so on, with the code key printed on the sheet. Codes are quick and staff know them, but they say very little. Refused does not say what was offered, whether it was offered again, or what the resident said. eMAR replaces codes with a reason list and a required note, and the note is where the value lies: refused, offered twice, said she felt sick, GP informed.

When you set up the eMAR, review the reason list with the seniors. Keep it short, make sure it covers the real situations in your home, and agree what a good note looks like for each. Then audit the notes in the first month. A reason list is only better than a code if the notes behind it are better than a letter.

Controlled drugs and the witness

Controlled drugs keep their register, their cupboard and their two-person check. What changes is that the witness signs on the device with their own log-in rather than in the book, the running balance is calculated rather than worked out by hand, and a discrepancy is flagged immediately. Many homes keep the paper register alongside for a period or permanently; check your policy and your pharmacist's advice, and be clear with staff which record is the legal one.

On day one, count every controlled drug with a witness and enter the balances as the opening figures. Then follow the system's process for every administration and every receipt. Our guide to controlled drugs in care homes covers the regulations and the audit. The eMAR does not change them; it makes compliance visible.

Stock, ordering and the Friday problem

Every home has had the Friday afternoon discovery that a resident's medicine will run out on Saturday. On paper, stock is counted at cycle end and estimated between. On eMAR, every administration reduces the balance, so the current stock of every medicine is known at any moment, and a low-stock warning arrives days before the shortage. Receipts from the pharmacy are recorded on the device and the balance updated.

The first cycle is the awkward one. Opening balances must be counted and entered for every medicine, which takes an afternoon for a home of thirty, and any miscount will surface as a discrepancy a week later. Do the count with two people, medicine by medicine, on the day before go-live, and treat the first cycle's discrepancies as counting errors to be corrected rather than as administration errors to be investigated, unless the pattern says otherwise.

Late and missed doses become visible the same hour

Time-critical medicines, such as those for Parkinson's disease, antibiotics, insulin and anticoagulants, need to be given within a window, and paper cannot show whether they were. eMAR records the time of every administration and can flag a dose given outside its window. The manager's dashboard shows late and missed doses for the shift, and the senior can see them before the round is closed.

This changes how the manager works. Instead of reading MAR charts at the end of the month, the manager or deputy checks the dashboard each morning, looks at anything late or missed, and speaks to the senior the same day. Errors are corrected while they are still small and the learning is immediate. It also produces the audit evidence that inspectors ask for under medicines optimisation, without anyone having to compile it.

Instructions on screen: covert, crushed, thickened and with food

Instructions that live on the back of a paper MAR chart, or in the care plan, or in the senior's head, sit on the eMAR screen at the moment of administration. Give with food. Do not crush. Thicken to level 2. Covert administration agreed, see best interests decision dated March. Swallowing assessed by speech and language therapy, tablets to be given in yoghurt. Allergies in red. Preferred way of taking medicines from the care plan.

Enter these carefully during set-up, because an instruction that is wrong on screen is followed more confidently than a wrong note on paper. Link the eMAR to the resident's care plan so that how the person likes to take their medicines and any capacity decisions are visible from the same place, and review instructions at every medicines review.

Homely remedies, creams and the charts that get forgotten

Topical creams, eye drops, thickeners, nutritional supplements and homely remedies are the medicines most often missed on paper, because they live on separate charts, in bedrooms or in the kitchen. On eMAR they are part of the resident's record and appear on the round or on a separate care round for care workers who apply creams. That means they are recorded, with a body map in the daily log where relevant, and their absence is visible.

Decide before go-live who records what. In many homes care workers apply creams and record them; seniors give oral medicines. The eMAR needs permissions that match, so that a care worker can record a cream but not sign for a tablet. Homely remedies need their signed list entered with the maximum doses so that the system can check them.

The medicine dictionary and pharmacy set-up

An eMAR needs the medicines entered correctly, and the two routes are electronic supply from the pharmacy or manual entry from the pharmacy's current medication record, picked from a medicine dictionary rather than typed. A dictionary of several hundred medicines with standard doses, forms and routes removes the transcription errors that handwritten MAR additions produce, and it means a change of dose is logged as a change rather than scribbled over.

Talk to the pharmacy at least four weeks before go-live. Agree how the medication records will reach you, whether they can supply electronically, how mid-cycle changes will be communicated, and how the first cycle will be handled. Ask the pharmacist to check the entered medicines list for every resident against their record before the first round. This one step prevents most of the serious day-one errors.

Agency seniors, permissions and accountability

On paper, an agency nurse or senior initials the MAR chart and nobody knows afterwards who those initials were. On eMAR every administration is attributed to a named log-in, which means agency staff need their own account for the shift with permission to administer medicines and nothing more. A shared senior log-in defeats the purpose and is a data protection failure.

The eMAR should let the manager create a today-only account in a minute at the start of a shift, and expire it automatically. Include a five-minute induction on the device in the agency induction checklist. It is also worth being clear that the eMAR makes agency staff safer, because the medicines, instructions and PRN protocols are on the screen rather than in a folder they have never seen.

What goes wrong on day one

The same things go wrong in most homes, and knowing them is most of the cure. The device battery is flat, or the wifi does not reach the end bedroom and the senior does not know the system works offline. A resident is missing from the round because they were admitted after set-up. A medicine is on the screen with the wrong time because the pharmacy record said morning and the resident has always had it at lunch. A senior panics at an outstanding dose and records it as given to clear the screen. Someone writes on the paper MAR as well, so there are two records. The controlled drug balance does not match because the opening count was wrong.

Each has a simple prevention: charged devices with spares, an offline test in the worst corner, a final check of the resident list the evening before, a walk through every resident's times with the senior, a clear instruction that outstanding means not given until you know otherwise, paper MARs removed from the trolley and kept in the office, and a witnessed count. Have a champion and the manager on the floor for the first two rounds.

eMAR training and competency

eMAR training has two parts and homes often do only the first. The first is how to use the device: open the round, record a dose, record a reason, give a PRN, sign as a witness, record a receipt, what to do offline. It takes an hour per senior and is best done on the real system with test residents. The second is competency: an observed round on the live system in the first fortnight, signed off by the manager or a nurse, with the same standard as any medicines competency assessment.

Refresh the training at two weeks and two months, when the questions are real. Keep the sign-offs in the training matrix alongside the medicines competency. Inspectors will ask how staff were trained on the eMAR and whether competency was checked; the answer should be a record, not a recollection.

A procedure for the week before go-live

1. Reconcile every resident's medicines list against the pharmacy's current record, resolve discrepancies with the GP, and have the pharmacist check the entered list.
2. Write and enter a PRN protocol for every as-required medicine, with the maximum in 24 hours and the minimum gap.
3. Enter administration instructions, allergies, covert decisions, swallowing requirements and homely remedies for every resident.
4. Create an individual log-in for every senior, nurse and care worker who will record, with the right permissions, and agree the agency process.
5. Train every senior on the device with test residents, and schedule the observed competency round for the first fortnight.
6. Test the devices in every part of the building, including offline, and charge spares.
7. The day before, count all stock and controlled drugs with two people and enter the opening balances.
8. Remove paper MAR charts from the trolley, file them in the office, and print a paper fallback for each resident in a sealed envelope for emergencies only.

A go-live day checklist

• Manager or deputy and a champion on the floor for the first two rounds.
• Devices charged, spare device available, offline behaviour explained again.
• Resident list checked against the building, including any weekend admission.
• Each resident's times walked through with the senior before the 8am round.
• Outstanding doses treated as not given until confirmed; nothing recorded to clear a screen.
• Controlled drug administrations witnessed on the device from the first dose.
• Every omission and PRN reviewed by the manager at the end of the day with the senior.
• Pharmacy and GP told the home is live and how mid-cycle changes will now be handled.
• A short note from each senior at the end of the shift on what was confusing, collected for the two-week refresher.

The first audit and the numbers that change

Run the first medicines audit at the end of the first cycle rather than waiting a month, and run it from the system's reports: missed and late doses, omissions by reason, PRN administrations with reasons and follow-up, stock discrepancies, controlled drug balances. Compare against the last paper audit and expect the recorded omissions to be higher and the unexplained gaps to be zero. That combination is success, and it needs explaining to the provider and, later, to the inspector.

Over the following months the numbers that should fall are unexplained omissions, late time-critical doses, stock run-outs and PRN without reasons. The number that should rise is the proportion of PRN with a recorded effect. Medication errors that reach a resident should fall too, and when one happens the eMAR gives the incident review a complete, timestamped account of what was recorded and by whom.

Nursing, residential and learning disability homes

The round is different in different services and the eMAR set-up should reflect it. In a nursing home, nurses administer complex regimes, injections, syringe drivers and enteral medicines, and the eMAR needs to handle them without workarounds. In a residential home, senior care workers administer from a smaller list and the emphasis is on simplicity and PRN. In learning disability and mental health homes, medicines for distress and behaviour need PRN protocols tied to the positive behaviour support plan, with ABC records alongside, and the eMAR should make it easy to see whether PRN use is rising for a person and why.

Ask the supplier to show your kind of round, not a generic one. The test is whether a senior in your home could do the 8am round on the device on the first day with the manager standing beside them and nothing on the screen that does not belong there.

Common mistakes

• Building the medicines list from the old MAR charts rather than the pharmacy's current record.
• Going live without PRN protocols, so the system asks for reasons against a blank.
• Keeping paper MAR charts on the trolley, producing two half-records.
• Shared log-ins for seniors or agency staff, making every administration unattributable.
• Recording an outstanding dose as given to clear the screen.
• Panicking at the first month's rise in recorded omissions and turning off prompts.
• Training on the device but never observing a competency round on the live system.
• Not testing offline working, and discovering it in the end bedroom at 8am.

What good looks like on inspection day

The inspector asks to follow three residents' medicines. The senior opens each on the device: the medicines list matches the pharmacy record and the cupboard, allergies are on screen, every dose in the last month is recorded with a time and a name, the two omissions have reasons and notes and the GP was told about one of them, the PRN pain relief given last Tuesday has a reason, a protocol on screen and an effectiveness check an hour later. The controlled drug balance on the device matches the cupboard and the register, with two names on every entry. The manager shows the missed and late dose report for the quarter with a note against each entry and the falling trend since go-live, the observed competency sign-offs for every senior, and the agency account created for last night's nurse. The inspector asks the senior what would happen if the wifi failed and the senior explains the offline mode and the sealed paper fallback. Nothing has to be found, and the round is already half done.

Final conclusion

eMAR does not change how medicines are given; it changes how the giving is recorded, and it removes the places where a paper MAR chart lets a careful person make an invisible mistake. The first day goes well when the medicines list has been reconciled with the pharmacy, PRN protocols exist, every senior has been trained and observed, stock has been counted with a witness, the devices have been tested in the worst corner, and the paper has been taken off the trolley. After that the manager sees the round the same hour instead of at the end of the month, and the audit evidence writes itself.

Frequently asked

Does eMAR change how medication is given in a care home?

No. The clinical judgement, the checks, consent and the medicines policy stay the same, and NICE guideline NG67 still applies. eMAR changes the recording: doses cannot be left blank, PRN needs a reason, stock counts itself, controlled drugs are witnessed on screen and gaps are visible the same hour rather than at the monthly audit.

What is the difference between a MAR chart and eMAR?

A MAR chart is the paper record of medicines prescribed and doses given, initialled by staff with codes for doses not given. eMAR is the same record on a device, with reasons required for omissions, timestamps, named users, automatic stock counts and manager dashboards. Both are legal records of administration.

Why do recorded missed doses go up when a home starts eMAR?

Because omissions that were blank boxes on paper are now recorded with a reason. The doses were always being missed; the system makes them visible. Treat the first month as the true baseline, review each omission, and expect the number to fall as staff adjust.

What eMAR training do care home staff need?

Two parts: how to use the device, taught on the live system with test residents, and an observed competency round on the live system in the first fortnight signed off by the manager or a nurse. Refresh at two weeks and two months and keep the sign-offs in the training matrix.

Do controlled drugs still need a witness with eMAR?

Yes. The second person signs on the device with their own log-in rather than in the book, and the running balance is calculated. The cupboard, the register and the safe custody regulations are unchanged. Many homes keep the paper register alongside; check your policy and pharmacist's advice.

What should a care home do the week before eMAR go-live?

Reconcile every medicines list with the pharmacy, write and enter PRN protocols, and enter instructions and allergies. Create individual log-ins with the right permissions, train the seniors and schedule competency rounds. Test devices offline in every part of the building, and count stock and controlled drugs with two people the day before.

Can agency nurses use a care home eMAR?

Yes, with their own account for the shift, created by the manager with permission to administer medicines and expiring automatically. A shared log-in makes every administration unattributable. The eMAR makes agency staff safer because instructions and PRN protocols are on the screen in front of them.

What happens to the eMAR if the wifi goes down?

A well-designed eMAR works offline and synchronises when the connection returns, and staff should be shown this before go-live. Every home also needs a sealed paper fallback for each resident and a business continuity plan for a longer outage. Test both before the first round.

Sources

• NICE guideline NG67 Managing medicines in care homes
• NICE quality standard QS85 Medicines management in care homes
• CQC: medicines information for adult social care services
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12
• Royal Pharmaceutical Society: professional guidance on the safe and secure handling of medicines
• Misuse of Drugs (Safe Custody) Regulations 1973
• Skills for Care: medication administration competency guidance