What should be documented if a medication cannot be administered?

Documenting the reason for non-administration of a medication is a critical component of effective healthcare practice. It provides essential information for other healthcare providers regarding the patient's care plan and informs them of potential issues that may need to be addressed. If a medication is not administered, noting the specific reason—such as a side effect, adverse reaction, patient refusal, or another valid concern—ensures that continuity of care is maintained. This information can be vital for the resident's ongoing treatment and can aid in making future decisions regarding their medication regimen.

While other documentation might be important in some contexts, they do not capture the specific circumstances surrounding the non-administration. The time the medication was supposed to be given, the resident's feelings, and the initial evaluation may provide context or background, but they do not directly address the immediate issue of why the medication was not given, which is crucial for ongoing patient management and safety.