A patient refuses a prescribed oral medication. Which documentation is most appropriate?
Correct answer: B. Medication refused, reason given, and prescriber informed
- A. Medication given because it remains prescribed
- B. Medication refused, reason given, and prescriber informed
- C. Medication omitted without an entry to avoid blame
- D. Medication held and recorded as a medication error
Explanation
The nurse records the refusal, the patient’s stated reason when available, the assessment, and the actions taken, including notification of the prescriber when needed. A refusal is not automatically a medication error, but leaving the record blank is unsafe.
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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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