In the case of a missed medication administration, what should the nurse document in the client's medical record?

When documenting a missed medication administration in a client's medical record, it is crucial to provide a clear and factual account. Documenting the missed medication administration ensures that there is a permanent record indicating that the prescribed medication was not given as ordered, which is important for patient safety and continuity of care.

This documentation serves several essential purposes. It not only alerts other members of the healthcare team about the missed dose, encouraging them to monitor the patient for any potential effects of missing the medication, but it also allows for appropriate follow-up actions to be discussed and documented. Additionally, having a record of the missed administration can help prevent confusion and ensure accountability.

While it is also important to document the reason for the missed medication, the specific time it was due, and any reactions from the patient regarding the missed dose, the primary focus of documentation in this case is on the fact that the medication was not administered as scheduled. This direct and explicit note forms the basis for any further actions needed regarding the patient's treatment plan or management.