What should you do if a medication is refused or missed?

What should you do if a medication is refused or missed?

• A. Circle initials on MAR and note why not given on back
• B. Erase MAR
• C. Document in a separate notebook
• D. Ignore and proceed

Answer: (A)

Maintaining an accurate medication administration record is essential for patient safety and accountability. When a dose is not given because the patient refuses or misses it, you must clearly indicate this on the MAR and record the reason. Circling the patient’s initials on the MAR to show the dose was not administered, and noting why on the back (or the designated section), creates a single, traceable entry. This helps anyone reviewing the record understand what happened, prevents inadvertent re-dosing, and guides the next steps (re-offering if appropriate, notifying the prescriber, and documenting the refusal). Erasing the MAR obscures information, while using a separate notebook or ignoring the dose breaks the continuity of care and safety.

Maintaining an accurate medication administration record is essential for patient safety and accountability. When a dose is not given because the patient refuses or misses it, you must clearly indicate this on the MAR and record the reason. Circling the patient’s initials on the MAR to show the dose was not administered, and noting why on the back (or the designated section), creates a single, traceable entry. This helps anyone reviewing the record understand what happened, prevents inadvertent re-dosing, and guides the next steps (re-offering if appropriate, notifying the prescriber, and documenting the refusal). Erasing the MAR obscures information, while using a separate notebook or ignoring the dose breaks the continuity of care and safety.