When a medication dose is held, what should you document?

When a medication dose is held, what should you document?

• A. Record as held with reason and time; inform supervising nurse; update MAR.
• B. Leave MAR unchanged and inform resident next shift.
• C. Record as given and note no change.
• D. File the note in the nurse's log only and ignore MAR.

Answer: (A)

When a dose is held, the important practice is to document the hold clearly: record the time the dose was held and the reason for the hold, notify the supervising nurse, and update the medication administration record to show that the dose was not given. This creates an accurate, auditable trail and keeps the whole care team informed, preventing accidental re-dosing and ensuring future decisions are based on current information. The MAR is the primary source of truth for what was and wasn’t given, so leaving it unchanged or marking the dose as given would misrepresent the patient’s care. Merely filing a note in another log without updating the MAR also risks miscommunication across shifts and staff.

When a dose is held, the important practice is to document the hold clearly: record the time the dose was held and the reason for the hold, notify the supervising nurse, and update the medication administration record to show that the dose was not given. This creates an accurate, auditable trail and keeps the whole care team informed, preventing accidental re-dosing and ensuring future decisions are based on current information. The MAR is the primary source of truth for what was and wasn’t given, so leaving it unchanged or marking the dose as given would misrepresent the patient’s care. Merely filing a note in another log without updating the MAR also risks miscommunication across shifts and staff.