When a dose is missed or administration is delayed, which steps should be documented?

• A. Date/time, reason, action taken, and notify nurse
• B. Only date/time
• C. Only reason
• D. No documentation

Answer: (A)

When a dose is missed or administration is delayed, you must capture what happened thoroughly to keep the patient safe and ensure continuity of care. Document the exact date and time the dose was missed or delayed, the reason for the omission or delay, the action you took (such as giving the dose as soon as possible, rescheduling it, or holding it per policy), and that you notified the nurse or supervising clinician. This complete record shows what occurred, why it happened, what was done in response, and who was informed, helping prevent dosing errors or gaps in treatment. Recording only the date/time or only the reason leaves out critical details and can lead to confusion or safety risks. No documentation at all is unsafe and can disrupt proper care.