Best way to document late medications

[HSclinicaleducator]

Greetings, all! Case in point: Understaffed, too many patients, medications late. What is the best way to document the reason for late medications using our electronic documenting system? It has every option in the world, but the reality is, just what it is...we have too many patients and we are understaffed to give ALL the medications in our time window of an hour before and/or an hour after. Thanking you in advance!

[Rose_Queen, BSN, MSN, RN]

We use "not given at scheduled time". Simple enough without trying to use a patient record as a weapon against poor staffing.

[TheCommuter, BSN, RN]

Due to your user name, I assume you use a Cerner-based computer documentation program called ACEIT. If so, you are correct that many reasons for late medications are provided, so all the nurse would need to do is click one of these.

I would never admit anywhere on the medical record anything about understaffing or too many patients, although that is par for the course in acute rehabilitative nursing. Disclosing staffing problems on the medical record opens the hospital up to potential litigation. When I use ACEIT, I click 'nursing judgment' as my reason for the lateness.

[VANurse2010]

Fortunately, our PCS gives a wonderful "Not given at scheduled time" as stated above. However, I'm not sure "nursing judgment" is really a better option - seems like it would just expose the nurse if there's an untoward event.

[boggle, ASN, RN]

I always felt that " not given at scheduled time" or " nurses judgement" needed some follow up charting to explain why. Sigh, more work.

(i always wished for an option to click on that said " meds arrived on time, given late because patient in bathroom. )

[MunoRN, RN]

We have the option in our drop down box for that a med is late due to "workload". This goes for anything that should have been done but wasn't due to excessive workloads and is also used by other specialties such as PT, if they have an order to see a patient but can't get to them they chart an assessment note that says "Patient not seen today due to workload". I'm actually pretty astounded that there are nurses who don't think this should be charted accurately. While I'm sure your hospital would love that the nurses take the fall for their inadequate staffing, I'm not sure why we're so willing to do so. If a patient is going to sue because a med was late or because they missed PT, why would you as the nurse want hide the fact that at least some of the blame lies with the staffing issue. And how would that go in court? "Mrs Nurse I see that you gave the patient's medication late and it appears you charted it was late because of such-and-such", "no it was late because I was unable to pass all my patient's medications safely in the goal timeframe", "why didn't you chart that?", "because I falsified my charting to protect the facility". Good luck keeping your license after that.

[PacoUSA, BSN, RN]

Our handheld scanners give us the option to choose TREATMENT IN PROGRESS as an option for meds being late, unless of course it is due to the patient being off unit or no IV access, there are options for those. However, for med late due to acuity, I use the treatment in progress reason. If the meds are a few minutes late as in 65 or 70 minutes past scheduled time, I usually don't comment. But anything later than that I do make a comment on the MAR time entry itself rather than a separate note. My former hospital had us do SBAR type nursing notes for each late or refused med, which I think is stupid when documenting under the MAR time entry is the same thing and much more efficient.

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[VANurse2010]

We also have a "patient/unit acuity" option for why a medication is given late. I believe we're supposed to file an incident report if we use that one, but that may or may not get done depending on the situation.

[onedayitllbeme]

Well I was told to think of it this way. A daily medication that is scheduled for 10am. You give it at 11:30am. You select ' dose rescheduled' is it late? No, it is a 'daily' medication and they got it yesterday and today. 10am. 11:30 2pm. OK for most meds. Now for antibiotics it is a little trickier we try harder to get them on time and document the reason why if we can't be it loss of iv access. Medication not available.. But never 'too busy' lol.

[onedayitllbeme]

If it really is too busy like we had a code or something probably would go as 'dose rescheduled' and cross your fingers. We are human after all. we try our best but sometimes it happens.

[SpyderWebb]

I add a note reading "Medication administered late due to prioritization of patients needs".

[gouranga]

"Patient sleeping" is an option in our system. Works every time.