What must be documented if a medication is missed?

When a medication is missed, it is crucial to document that fact accurately to maintain a clear and accountable medication administration record. The most appropriate form of documentation involves signing the documentation box with initials, often emphasized with a circle around the initials for clarity. This practice ensures that anyone reviewing the chart can quickly understand who was responsible for the administration of medications and that they have acknowledged the missed dose.

This method not only enhances accountability but also serves as a visual marker that can be easily identified by other healthcare providers. Documentation must also be consistent and adhere to the facility's policies regarding medication administration, ensuring an accurate medical record. It is important to remember that while noting the missed medication on the client's chart is essential, it does not carry the same clarity and significance of using initials with a circle for immediate recognition.