A nurse is unable to give a scheduled medication because the patient is temporarily away for a diagnostic test. What is the best documentation?
Correct answer: C. Record that it was withheld, state the reason and follow policy
- A. Record the medication as given at the scheduled time
- B. Leave the medication record blank without further action
- C. Record that it was withheld, state the reason and follow policy
- D. Ask another nurse to sign for the medication instead
Explanation
The nurse should accurately record that the medication was not administered and document the reason, following local policy for rescheduling or notifying the prescriber. Signing it as given creates a false legal record.
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About Documentation, Reporting and Communication
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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