What should you do if you suspect a dose was given but not documented?

What should you do if you suspect a dose was given but not documented?

• A. Document promptly and report to supervisor.
• B. Do not document until the next shift.
• C. Delete the record and proceed.
• D. Ask the resident to confirm.

Answer: (A)

When a dose seems to have been given but isn’t documented, the priority is to keep an accurate, complete medication administration record and involve supervision right away. Documenting promptly reflects what you believe happened and provides a traceable account for the care team. Then inform your supervisor so they can check the MAR, verify with the resident or other staff as needed, and determine whether the dose was given, missed, or needs adjustment. This approach supports patient safety by preventing missed or double dosing and ensures accountability. Waiting until the next shift to document, altering or deleting records, or asking the resident to confirm the dose does not provide a reliable or safe path forward. These actions can mask errors or lead to improper dosing and undermine the integrity of the medication record.

When a dose seems to have been given but isn’t documented, the priority is to keep an accurate, complete medication administration record and involve supervision right away. Documenting promptly reflects what you believe happened and provides a traceable account for the care team. Then inform your supervisor so they can check the MAR, verify with the resident or other staff as needed, and determine whether the dose was given, missed, or needs adjustment. This approach supports patient safety by preventing missed or double dosing and ensures accountability.

Waiting until the next shift to document, altering or deleting records, or asking the resident to confirm the dose does not provide a reliable or safe path forward. These actions can mask errors or lead to improper dosing and undermine the integrity of the medication record.