MEDICATION AUTHORISATION FORM

It was agreed at an assessment with a social worker or care manager that a home care provider will help to administer your medication.  

To be read and completed by the service user or their authorised representative[1]:

I give authorisation for care workers from my home care provider to assist with the administration of medication as prescribed by my GP or other authorised prescriber. If applicable, I also give authorisation for my care workers to administer non-prescribed medication in accordance with the agreed non-prescribed list[2].

I understand that:

  • Care workers can only administer medication recorded on the Medication Administration Record (MAR chart) at the prescribed level.
  • Anyone who administers my medication, including, for example, my carer or a family member, will record the details on the MAR chart. Administration of any non-prescribed medication will be recorded in the home care provider’s log book.
  • My care workers will follow the guidance set out in the Sheffield Medication Policy.

I agree that:

  • I will make available to my care workers / home care provider the MAR chart and any other records relating to my medication.
  • I authorise my care workers / home care provider to communicate with my GP, pharmacy or any other prescriber about my medication and issues that arise.
  • My details can be shared with my pharmacy to enable them to produce a MAR chart for use within my home.
  • Where necessary I will give as full information as possible to my care workers / home care provider about my medication including what I have and have not taken.
  • I will cooperate with my care workers / home care provider to enable them to safely administer my medication, ensuring that my medication is appropriately stored. I will also enable them to appropriately dispose of medication that is no longer prescribed, out of date or is spoilt and cannot be used safely.
  • My home care provider will keep my MAR chart when it is completed for audit purposes.

[1] The form should only be completed by a representative of the service user by exception, for instance due to a physical or cognitive impairment.

[2] http://www.sheffield.gov.uk/content/sheffield/home/disability-mental-health/medication-policy.htmlv

  • My details can be shared with my pharmacy to enable them to produce a MAR chart for use within my home.
  • Where necessary I will give as full information as possible to my care workers / home care provider about my medication including what I have and have not taken.
  • I will cooperate with my care workers / home care provider to enable them to safely administer my medication, ensuring that my medication is appropriately stored. I will also enable them to appropriately dispose of medication that is no longer prescribed, out of date or is spoilt and cannot be used safely.
  • My home care provider will keep my MAR chart when it is completed for audit purposes.

Please refer to below to see the information your home care provider will share with your pharmacy.

A Medication Authorisation Form is to be completed in full on the first occasion an individual requires support with medication administration as part of a home care package.

In the event a service user transfers to a new provider, the original Form remains valid.  In the event of any changes, the pharmacy must be informed (see page 5).

All providers will adhere to the Sheffield Medication Policy when administering medication: http://www.sheffield.gov.uk/content/sheffield/home/disability-mental-health/medication-policy.html

If there is another individual(s) i.e. carer or family member who it is more appropriate to contact, please detail below:
HOME CARE PROVIDER
EMBRACE HEALTHCARE LTD
CONTACT TELEPHONE
01302481515
THE SERVICE USER REQUIRES SUPPORT WITH (please tick applicable boxes):
The Form must be completed by the home care provider at the point of undertaking the initial assessment with the service user and sent to the specified pharmacy and the service user’s GP by one of the following methods:
 In person
 Fax
 Post
The pharmacy will only supply MAR charts upon receipt of a fully completed Form.
The home care provider will ensure a copy of the Form is retained in the following locations:
 The service user’s file in their property
 The service user’s file at the provider’s local office
To be completed by the Pharmacy:
Pharmacies will supply a MAR chart for adults aged 18 and over in receipt of home care funded by the Council (including both in-house services and any organisation delivering services on behalf of the Council) who is assessed as requiring support at Level 2, i.e. where the Care Worker is responsible for ‘removing medication from the container and directly administering’ the medication. Monitored Dosage Systems (known as a NOMAD) should only be used by exception where an individual requires support at Level 2. The pharmacist will supply a separate, standardised MAR chart for the care worker to record administration of medication from the MDS.

REVIEWING & UPDATING THE AUTHORISATION FORM

In the event that any of the details on the form change, the home care provider will inform the pharmacy at the earliest opportunity, recording the details in the box below:
ENDING THE SERVICE
The home care provider must inform the pharmacy when they no longer require a MAR chart for this service user by completing the following table and returning the form to the pharmacy via one of the methods described on page 4:
 

Embrace Health Care will not accept a partially complete application and if any of the forms are missing we can not guarantee your application will be considered.  For each form you will receive a confirmation email confirming the submission and we recommend that you retain this as proof.  On submission you will be redirected to the next form but you do not need to complete within a specified time as long as all are received prior to the closing data of the advertised position.