What a Medication Administration Record Must Contain in Australia
A medication administration record exists to answer one question after the fact: what happened. Here is what an auditor, a pharmacist, or a coordinator expects a MAR to contain, and why the reason field is never optional.
The short answer
A medication administration record, or MAR, is the document that shows, for every scheduled dose, what medication was due, whether it was given, and who recorded it. In Teiro, the care management platform used by Australian NDIS and aged care providers, that record exists as a monthly grid view and a daily view grouped by time of day, and every entry is signed regardless of the outcome. This guide covers what a MAR needs to contain to actually stand up to scrutiny, not just what a template looks like.
Watch the walkthrough
A medication administration record in Teiro shows every scheduled dose grouped by time of day, the client's active medications, and a signed Webster pack slot where each packed medication still keeps its own signed history. A PRN dose is recorded separately, with what prompted it and what effect it had.
Today's doses grouped by time of day, the active medication list, a Webster Pack slot expanded to show each medication's own signed history, and a PRN dose recorded with its trigger and effect.
The steps below cover the same ground in writing, including what still has to be true regardless of whether a dose comes from a pack or from original packaging.
The core elements of a MAR
Whatever system produces it, a medication administration record needs to show, for each scheduled dose:
- Who the client is. Unambiguous client identification against every entry, not just at the top of the page.
- What the medication is, including the strength and form, not just a brand name that could refer to more than one product.
- The scheduled time. When the dose was due, not just the day.
- The outcome. Given, refused, withheld, self-administered, not supplied, or missed. A blank entry is not a record of anything; it is a gap.
- Who recorded it, with a signature. On a paper MAR this is an initial in the box. On a digital MAR it is a signed entry tied to a specific user. Either way, an unsigned entry does not count as documented.
- The medication's schedule classification, general, S4, S4D, or S8, because controlled drugs carry additional handling and audit expectations.
- A reason wherever the outcome is not "given". A refused, withheld, or missed dose without a reason tells a reviewer that something happened but not what to do about it. See below for why this field is never optional.
Why the reason field is never optional
"Refused" on its own is not useful information. Refused because the client said no and was capable of making that decision is a very different situation to refused because the client was too drowsy to safely swallow a tablet, and both are different again from a dose withheld on a GP's verbal instruction pending review. Each of those needs a different next step, and none of them is visible from the word "refused" alone.
A MAR that records the outcome without the reason answers "did the dose go in" but not "should someone be worried." That second question is the one a coordinator, a family member, or a reviewing nurse actually needs answered, and it is why a reason field attached to any non-given outcome should never be treated as optional, in any system.
PRN medications need more than the other rows
A PRN (as-needed) medication cannot be documented the same way as a scheduled one, because there is no fixed time to check it against. A PRN entry on a proper MAR needs, in addition to the elements above:
- What triggered the dose. The symptom or situation that led to it being given.
- The effect. Whether it worked, part-worked, or made no difference.
- How many doses have been given in the relevant period. Visible against the medication, not reconstructed from scattered entries.
What "prompting," "assisting," and "administering" mean for the record
These three are different actions and the record should distinguish them, because they carry different levels of responsibility:
- Prompting is reminding a client it is time for their medication and that it is available, without physically handling it.
- Assisting is helping a client take their own medication, for example opening a packet or handing over a glass of water, while the client remains the one taking it.
- Administering is a support worker giving the medication directly.
Which of these is happening for a given client and medication should be set out in their medication management plan, and the record of what actually occurred should be consistent with it. Getting this distinction blurred in the documentation is one of the more common gaps reviewers find.
Retention and audit readiness
How long a medication record needs to be kept, and exactly what a specific state health department or the NDIS Commission expects to see during an audit, are questions that sit with your own regulatory obligations and your organisation's policies rather than with this guide. For the broader picture of what an NDIS audit asks for, including where medication records fit alongside qualification records, service agreements, and incident reports, see NDIS audit preparation: the twelve documents you will be asked for.
How Teiro structures this
Teiro's MAR gives every client a monthly grid view for the shape a coordinator or an auditor expects, and a daily view grouped by time of day for the view a support worker actually works from on a visit. Every entry, given or not, is signed. PRN medications carry their trigger and effect on each entry. Controlled drug entries step up to a fresh biometric or PIN confirmation rather than a saved one-tap signature. See the full medication management feature page, and how Webster pack pocket signing fits alongside individual medication entries.
Frequently asked questions
What is the difference between a MAR and a medication chart?
In Australian usage they generally mean the same thing: the ongoing record of what was administered against what was scheduled. "MAR chart," a term used in the UK, is not standard Australian terminology; Australian providers more commonly say "medication chart" or "medication administration record."
Does a missed dose need to be recorded, even if it was an accident?
Yes. A missed dose is still an outcome, and it needs a signed entry with a reason, the same as a refused or withheld dose. An unrecorded missed dose looks, on the record, exactly like a dose that never should have happened in the first place, which is a worse position for a provider to be in than an honestly recorded miss.
Do PRN and scheduled medications need to be on the same record?
They should sit in the same overall medication record for the client, but a PRN entry needs to carry its own trigger and effect, which a scheduled dose does not. Keeping them in one place, rather than a scheduled MAR in one system and a PRN log in another, is what lets a reviewer see the full picture for a client at once.
Who should be able to see medication records versus record them?
That depends on your organisation's own role structure and clinical governance, but as a general principle, the ability to record a medication administration should be limited to roles that actually deliver or directly oversee support, not extended to every role in the system, such as billing-only roles that have no involvement in care delivery.
Want to see the MAR running with your own client and medication data? Book a demo or start free with up to five active users.
Full transcript
The full text of the walkthrough above, for anyone who would rather read it or needs it in text form.
What this recording shows
This is a 36 second screen recording of a medication administration record in Teiro, the care management platform used by Australian NDIS and aged care providers. It was captured on desktop, in the Teiro web platform, on the real product, following one client's medications from today's doses through to a signed Webster pack slot and a recorded PRN dose.
Where a medication record lives on a client's record in Teiro
A client record in Teiro carries a Medications tab alongside Detail, Contacts, Comms, Documents, Funding and Schedule, so every medication for that client sits in one place rather than a separate system. The client on this record is Harold Nguyen, and opening his Medications tab is the starting point for everything that follows: what is due today, the full medication list, the Webster Packs, and the Monthly MAR.
What the Administer tab shows for today's doses
The Administer tab groups today's doses into Morning, Noon, Evening and Night, with an allergy banner reading "Penicillin (rash). No known food allergies." pinned above the list. Teiro puts every dose due across the day on one screen, rather than a support worker paging through separate entries medication by medication.
What a medication administration record must show for each active medication
The Med List carries five active medications on this record: Salbutamol, Paracetamol, Perindopril, Atorvastatin and Metformin, each with its strength, form and start date. Paracetamol carries "Maximum 8 tablets in 24 hours" as a written instruction on the medication itself, for a support worker to read and follow. Teiro records the dose given; it does not enforce that limit or block an entry against it.
How the Monthly MAR groups packed doses into a Webster Pack slot
Teiro's Monthly MAR shows August 2026 as a grid against a status legend of Given, Refused, Missed, Withheld, Self admin, Absent, Not supplied and Overdue. A dose administration aid, commonly called a Webster pack, appears on the grid as a single Webster Pack group row per slot, collapsed by default; expanding that group row is what reveals the individual medications packed inside it.
What an expanded Webster Pack slot shows underneath the signature
Expanding the Webster Pack Morning group in this recording shows Metformin 500 mg and Perindopril 5 mg, each carrying its own row and roughly twelve days of signed G entries, even though both are packed into the same morning pocket. Teiro keeps a separate signed history per medication inside a pack slot automatically, so one signature on the pocket does not blur what was actually given underneath it.
How a PRN dose is recorded separately from the Monthly MAR grid
Salbutamol is the PRN medication on this record, and selecting it opens a batch sheet rather than a grid cell, with fields for what prompted the dose and what effect it had. Teiro records a PRN entry as its own record, separate from the scheduled doses on the Monthly MAR, because a PRN dose has no fixed time to check it against.
What Teiro confirms once a PRN dose is recorded
Teiro confirms the entry immediately: submitting the batch sheet in this recording produces a "Recorded" confirmation on screen, and the trigger and the effect entered on the batch sheet both land on the PRN entry, not just the fact that a dose was given. The trigger and effect captured here are what turn a PRN entry into something a coordinator or reviewing nurse can actually read back later, rather than a bare timestamp.
Every dose, every signature, one record
By the end of this recording the Webster Pack Evening slot shows Metformin marked G alongside the other closed-out slots, and the PRN event list carries the Salbutamol entry with its real trigger and effect pair attached. Teiro brings every scheduled dose, every packed slot and every PRN entry together on one medication administration record for an Australian NDIS or aged care client, which is what a coordinator, a pharmacist or an auditor is checking when they ask what actually happened.