Documentation when a medication was missed

[Elven_RN, ASN, RN]

I worked at a place that used paper MARs and there was an instance I missed a medication, so the spot for my initials was blank. My supervisor brought it to my attention and told me I needed to sign the box because the MAR could not have any holes when the state did its audit. I absolutely did not want to initial that I gave something when I know clearly that I did not! That's falsifying a document intentionally.

My question is, what is the right way to go about documenting something that wasn't completed, without making a mess for yourself?

Another nursing job also uses paper MARs and nurses there initial when pouring the med as opposed to after. I wasn't comfortable with this practice, waiting until after. Nurses also like to hand out other nurses' poured meds, so there were times I left spots on the MAR open when I know I didn't give the med. How does this get reconciled, especially if the other nurse doesn't remember? Should the nurse who poured it just go back and sign it?

[chare]

Unless there is some method designated on the MAR to indicate that the medication was not administered (typically at places I worked by circling the administration time), I wouldn't initial the entry either. 

[Elven_RN, ASN, RN]

chare said:

Unless there is some method designated on the MAR to indicate that the medication was not administered (typically at places I worked by circling the administration time), I wouldn't initial the entry either. 

Thanks! So what would you do about "holes in the MAR"?

[chare]

Your supervisor is correct, there shouldn't be any "holes" on the MAR.  However, this doesn't mean you should document a med that you didn't administer.

First, review the MAR for instructions on how you should document a missed dose. 

Second, if you don't see anything on the MAR, check your facility's policies.

Lastly, if you still haven't found anything discuss this with your manager.  Explain your concerns and ask her or him how you should document a missed dose.

Best wishes.

[Nurse Judi]

This happened to me once in Primary Care. The NP gave her daughter a vaccine and then told me I should document on it. She was not even my patient. We had gone to nursing school together and learned the same ethical rules. I told her I could/would not. She had her MA initial it and she did. 

[SuzanneRNLA]

Every place I've ever worked with paper MARS, if a med wasn't given, the time would be circled and initialed. Then documented in the narrative patient's record why med wasn't given.

[EdieBrous, BSN, MSN]

It is NEVER OK to falsify a medical record.  See if that is what you are being asked to do, or if you are being asked to explain "the hole" and if your boss actually does want you to falsify the record, tell her you would like a meeting with her and HER boss to see if that is really the direction the organization wants to go in.  The facility is better off with deficiencies that can be corrected than with allegations of record falsification and billing fraud.  And it isn't her license here, it's yours.  Willing to bet those directions are not in writing.

[JKL33]

Nurse Judi said:

This happened to me once in Primary Care. The NP gave her daughter a vaccine and then told me I should document on it. She was not even my patient. We had gone to nursing school together and learned the same ethical rules. I told her I could/would not. She had her MA initial it and she did. 

What is wrong with people. Specifically the NP in this instance. That is scary + goofball all rolled into one.

[JKL33]

Quote

My supervisor brought it to my attention and told me I needed to sign the box because the MAR could not have any holes when the state did its audit.

My general answer to a number of administration statements over the years (internally/to myself, of course) is as follows: X may be true, but that doesn't mean I *have to* do Y about it.

So applied to this scenario: It may be true that there should not be holes (aka unaddressed items) on the MAR, but that doesn't mean I have to falsify documentation in order to prevent holes. 

If I am directed to do something illegal (which I have been on occasion) I tend to respond in a very straightforward manner, such as "Uh, no."

In this case in the OP, I would have consulted facility policy and followed it, assuming it also didn't direct me to do something illegal. If there was no relevant policy I would make my own decision, which would be to fit in the tiny space "not given" or "see nn" (nurse's notes) then initial that statement. I'd much rather be clear and up front and have to answer for why it was not given than to give any appearance of false documentation. I prefer the "not given"/"see nn" and initials approach because circles and initialing inside/outside the circle is not very tamper-proof, anyone can go around circling things...they could even circle an already-initialed space if they're really a trouble-maker, etc.

The #1 purpose of a medical record is to serve as an accurate record of what happened to that patient. Clear record keeping for the benefit of the patient first and foremost.

[Corey Narry, MSN, RN, NP]

I am old enough to remember paper MAR's in the hospital. Back then, the MAR has a legend that tells you how to document if a med is given, not given, or given at a time later than what was scheduled. I remember having to circle the time with my initials and it would mean the medication was held. Could this be what the manager was asking you to do?