Documentation of Medication Administration

Core Concepts

The MAR and eMAR

The MAR is the legal record of every medication ordered and administered for a patient. It lists each medication, the dose, route, frequency, and scheduled times, with a space for the nurse to record each administration. Electronic systems (eMAR) add features such as barcode scanning, allergy alerts, and automatic time-stamping, and they often flag overdue or due doses. In both paper and electronic systems, the nurse verifies the order against the MAR before giving the drug and records the administration immediately after giving it — not before, and not at the end of the shift from memory.

What to document

For each dose, record:

• The drug name, dose, route, and time given.
• The administration site for injections (and the patient's tolerance of the procedure).
• The patient's response when relevant — for example, pain relief after an analgesic, or an adverse reaction.
• Any reason for omission: refusal, the patient was off the unit, the drug was held per order, or an error occurred.
• Anything unusual, such as difficulty swallowing the dose or a medication error and its follow-up.

Documentation should be objective and factual — what you observed, what the patient reported, what was done — not labels or judgments. "Patient reported nausea after the dose" is documentation; "patient is difficult" is not. Person-first language applies here too: document the person and the behavior, not a label.

Timing: the "right time" of documentation

Document immediately after administration. Charting before giving the drug ("charting ahead") is a serious violation — if something interrupts the administration, the record will claim a dose was given that was not. Charting hours later from memory risks errors and is also unacceptable practice. If documentation is delayed for a legitimate reason, follow facility policy for late entries, which usually involves noting the actual time and explaining the delay. In electronic systems, the entry is often time-stamped automatically, so there is no such thing as a "quiet" backdated entry.

Refusals, omissions, and errors

• Refusal: document that the medication was offered, the patient's stated reason (in their words when possible), the education you provided, and that you notified the provider. Respect the refusal while ensuring the patient has the information to make an informed choice.
• Omission: if a dose was not given (for any reason), document that it was omitted and why. An omission is a form of error unless it was intentional and ordered (e.g., "hold for procedure").
• Errors: patient safety comes first — assess the patient, notify the provider and the pharmacist per policy, and follow the facility's error procedure. Documentation in the medical record is factual and objective (what was given, when, and the patient's condition). The incident report is a separate, confidential document for the facility's review — it is not part of the medical record and does not replace charting the facts.

Legal and professional standards

• Timely, accurate, complete, and legible (for paper records).
• Use only approved abbreviations; never use banned "dangerous abbreviations" (e.g., "U" for units, trailing zeros).
• Never alter a record improperly. Corrections in paper records are made with a single line through the error, the correct entry, the date, and a signature — never with whiteout or erasure.
• Never document for another clinician, and never ask someone to document for you.
• Follow facility policy for two-person verification documentation (for example, when a second nurse witnesses a high-alert medication or a controlled-substance waste).

Person-first, objective language

The words nurses choose shape the record and the perception of the patient. "Patient declined the dose and requested more information" is documentation of a decision; "patient is noncompliant" is a label that carries judgment. Documenting behavior and speech accurately — including the patient's own words in quotation marks when useful — protects the patient's dignity and keeps the record factual.

Common Confusions