shift is wild

When it goes sideways

When the dose was given but the MAR missed it

For when the med made it to reality, but the eMAR stayed in its little fantasy world.

8 min read built on 6 full opinions updated 2026-09-21

Written by a med-surg RN, ten years, day shift. Why there is no name on it

Maya reacting to this topic

You gave the med. The barcode scan didn’t save, the eMAR click disappeared, or the MAR signature never stuck. Don’t chart around it. Fix the record so it shows what happened: the real administration time, why the scan or manual entry missed, the dose details, the patient response, and who you notified.

The short version

  • If the patient got the dose, don’t mark it as not given.
  • Enter a late or manual MAR entry with the actual administration time, not the time you found the problem.
  • Say why the scan or MAR entry failed: scanner failure, downtime, unreadable barcode, emergency workflow, wrong workstation, or another specific reason.
  • Include dose details: medication, dose, route, site or rate if relevant, amount removed, amount administered, amount wasted or returned, and witness if required.
  • For pain meds or sedating meds, add reassessment and notifications: pain score, sedation/respiratory status, effect, adverse effects, charge nurse/pharmacy/provider notice as applicable.

What goes wrong

The usual mistake is trying to make the MAR look clean instead of making it true. If you chart the scheduled 0900 time when the medication actually went in at 0947, you just created a false timeline. If you mark it not given, the next nurse may think the patient still needs it.

The note has to connect the dots: order, patient ID check, actual dose, actual time, reason the system missed it, patient response, and follow-up. If those pieces are scattered without a note tying them together, the dose can look unaccounted for, duplicated, late with no reason, or never reassessed.

It is not hypothetical

  • Wilkin v. Community Hospital of the Monterey Peninsula, California Court of Appeal, 2021. https://www.courtlistener.com/opinion/5298809/wilkin-v-community-hospital-of-the-monterey-peninsula/

This discrepancy left four milligrams of morphine unaccounted for; Wilkin admitted at her deposition that such a discrepancy should have been documented.

  • Heard v. Aultman Hosp., Ohio Court of Appeals, 2016. https://www.courtlistener.com/opinion/3186301/heard-v-aultman-hosp/

The waste of the remaining morphine was not documented on the anesthesia record.

  • Black v. Ohio Bd. of Nursing, Ohio Court of Appeals, 2022. https://www.courtlistener.com/opinion/9355865/black-v-ohio-bd-of-nursing/

You administered these drugs to the patient without documenting that you questioned the order(s) and/or consulted with any member of the health care team regarding the accuracy/validity of or harmfulness to the patient of these order(s).

  • Gabriel v. County of Herkimer, District Court, N.D. New York, 2012. https://www.courtlistener.com/opinion/8718656/gabriel-v-county-of-herkimer/

The Narcotics List also indicates DiCamillo was administered an 8:30 p.m. dose of Clonazepam but this was not documented in the Security Log or the Medication Administration Record.

What to write instead

How it often gets written How to write it
Med given. Scanner broken.Late eMAR entry completed at 1038. Oxycodone 5 mg PO administered at 1012 for pain 8/10 per active PRN order. Bedside scan did not transmit after two attempts due to scanner error on WOW-3. Patient identified with name and DOB; medication verified against active MAR before administration.
Morphine scanned wrong.Morphine 2 mg IV push administered at 1416 through left forearm PIV for pain 9/10. Unit-dose barcode unreadable; manual verification completed against active order and allergy list before administration. Charge RN A. Smith notified at 1425.
Wasted remainder.Hydromorphone 1 mg/1 mL removed from ADC at 0754. Administered 0.4 mg IV push at 0801 per order. Wasted 0.6 mg in medication room with J. Lee, RN, witness, at 0804. ADC discrepancy reviewed and resolved with witness.
Pain better.Pain reassessment at 0840 after hydromorphone: pain decreased from 8/10 to 3/10. RR 16, SpO2 96% on room air, POSS 1, patient awake and conversing, denies nausea or dizziness.
Provider aware.Dr. Patel notified at 1120 that ceftriaxone 1 g IV was administered at 1045 but initial MAR scan did not save during downtime. Manual late entry completed. No new orders received.
Forgot to chart last night.Late entry entered 06/14/2026 at 0715: Acetaminophen 650 mg PO was administered 06/13/2026 at 2220 for temp 100.8°F. MAR entry not completed at time of administration due to urgent transfer of another patient. Patient temp 99.4°F at 2325; no adverse reaction noted. Charge RN notified at 0718.

Words that do the damage

Word or phrase Why it hurts the note Use instead
ForgotSounds like a memory problem and does not tell what happened clinicallyLate entry. Dose administered at [TIME]. MAR did not capture because [REASON].
Scanner brokenToo vague; does not show what check was doneBarcode scan failed after [NUMBER] attempts on [DEVICE]. Patient and medication verified manually against active MAR/order.
Given as orderedLeaves out dose, route, time, and patient response[MEDICATION] [DOSE] [ROUTE] administered at [TIME] for [INDICATION].
WastedMissing amount and witness[AMOUNT] wasted with [NAME/TITLE] at [TIME] per controlled substance process.
Patient fineNot a reassessmentPain [SCORE], RR [NUMBER], sedation [SCALE], BP [VALUE], response [DETAILS], adverse effects [YES/NO].
Charting errorToo broadeMAR capture failure, late MAR entry, duplicate scan attempt, barcode unreadable, downtime entry.
I thinkAdds uncertaintyState only verified facts; if unsure, document what could not be verified and who was notified.

What the guidance says

  • If a dose is missed, refused, or not given as scheduled, don’t leave the MAR blank. Mark the MAR and document the reason in the right note or comment area. (OpenStax, Medicine LibreTexts/11:_Principles_of_Medication_Administration/11.03:_Documentation_of_Medication_Administration))
  • For a missed or refused medication, document the specific reason and follow facility policy for notifying the right person when notification is needed. (Aplmed Academy, Unanswered.io)
  • For clinically significant missed or delayed medications, add a nursing note with follow-up. Don’t rely only on a MAR reason code. (TheNewRN, Unanswered.io)
  • Keep the record accurate. Don’t pre-document or sign in a way that does not match what actually happened. (TheNewRN, allnurses)

Copy this

Chart note

```text Late MAR/eMAR clarification entered [DATE] at [TIME ENTERED]. [MEDICATION] [DOSE] [ROUTE] was administered to [PATIENT NAME/INITIALS] at [ACTUAL ADMINISTRATION TIME] for [INDICATION] per active order [ORDER DETAILS].

MAR/barcode capture did not complete at time of administration because [SPECIFIC REASON]. Before administration, patient identity was verified using [TWO IDENTIFIERS]. Medication, dose, route, allergies, and timing were verified against the active MAR/order by [NAME/TITLE OR N/A].

Dose details: [AMOUNT REMOVED] removed from [ADC/OTHER] at [TIME REMOVED]; [AMOUNT ADMINISTERED] administered; [AMOUNT WASTED/RETURNED/N/A] [WASTED/RETURNED/N/A] with [WITNESS NAME/TITLE/N/A] at [TIME] per facility process.

Pre-dose assessment: [PAIN SCORE/VITALS/SEDATION/RELEVANT ASSESSMENT]. Reassessment at [TIME]: [PAIN SCORE/RESPONSE/VITALS/SEDATION/ADVERSE EFFECTS].

[CHARGE RN/PHARMACY/PROVIDER] notified at [TIME]; response: [NO NEW ORDERS/NEW ORDERS/FOLLOW-UP]. Next dose timing reviewed and communicated to [NAME/TITLE] at [TIME]. ```

Message to charge nurse or supervisor

```text [NAME/TITLE], [MEDICATION] [DOSE] [ROUTE] was administered to [PATIENT NAME/ROOM] at [ACTUAL ADMINISTRATION TIME], but the MAR/eMAR did not capture the administration because [SPECIFIC REASON].

I completed a late/manual MAR entry using the actual administration time, documented dose details, and added reassessment at [REASSESSMENT TIME]. Controlled substance count/waste status: [RESOLVED WITH WITNESS/NON-CONTROLLED MED/N/A].

Notifications completed: [PHARMACY/PROVIDER/IT/OTHER] at [TIME]. Patient status at this time: [CURRENT STATUS]. Please advise if additional follow-up is needed. ```

Internal safety or variance report

```text Event type: Medication documentation/eMAR capture issue.

On [DATE] at [ACTUAL ADMINISTRATION TIME], [MEDICATION] [DOSE] [ROUTE] was administered to [PATIENT IDENTIFIER] per active order for [INDICATION]. Bedside scan/MAR entry did not capture at the time of administration due to [SPECIFIC SYSTEM OR PROCESS ISSUE].

Verification before administration: patient identity confirmed with [TWO IDENTIFIERS]; medication verified against active MAR/order; allergy check completed [YES/NO WITH DETAILS].

Dose details: [AMOUNT REMOVED] removed from [ADC/OTHER] at [TIME]; [AMOUNT GIVEN] administered; [AMOUNT WASTED/RETURNED/N/A] with witness [NAME/TITLE/N/A].

Record correction: late/manual MAR entry completed at [TIME ENTERED] using actual administration time [ACTUAL ADMINISTRATION TIME]. Patient assessment before dose: [ASSESSMENT]. Reassessment after dose: [ASSESSMENT/RESPONSE]. Notifications: [WHO WAS NOTIFIED], [TIME], [RESPONSE]. Patient outcome at time of report: [STATUS]. ```

If you remember one thing

Chart when the medication actually went into the patient. Then say why the MAR didn’t catch it.

Read the decisions yourself

Every case below is a published decision on CourtListener. Open them. Nothing on this page asks you to take our word for what a court said — and where we only had the search result rather than the full opinion, it says so.

All the decisions behind this guide, in one page — searchable by court, year, or what happened.

What people say on the floor

Nurses talking to each other about this, quoted as they wrote it. This is opinion, not a source. It is here because it shows what the argument actually is — the rules above come from the decisions and the published guidance, not from these threads.

  • Reverify the medication, SCAN THE PATIENT, scan the med against the MAR. ... Unless this is a code situation, my first stop when passing through the doorway with meds isn't to the patient and their IV.

    r/nursing on Reddit: Miscounted narcotics reddit

  • There are worse things that could happen in our field. ... Usually in the absence of any other signs of narcotic abuse, it would lead to a warning/written counseling (which seems to be the case).

    r/nursing on Reddit: Narcotic discrepancy reddit

  • I have a good friend who was in a similar situation, and HR two months later flat out lied and said “we asked for a urine test and she refused”. Turns out they had screwed up and were trying to cover their butts. A drug test at urgent care is $60. That’s a small price to have some back up that exone

    r/nursing on Reddit: Missing Narcotic- need advice reddit

  • They didn’t want me to just mark ‘scanner not available’ for the ativan even though the scanner wasn’t working. ... I know this isn’t the point of this post but you can open the hospital chart in discharged patients (it’s separate from the…regular chart. The chart chart. The one just called Chart) a

    r/nursing on Reddit: Missing Narcotic reddit

What everyone else says

Guidance from professional bodies, insurers and other people who write about this. Useful, but it is advice, not law — that part is above.

How would you chart it?

This is the part we cannot research. If you have a way of writing this that has held up — put it here. No account, no name needed. Nothing that could identify a patient: no room numbers, no dates of birth, no MRNs. Use placeholders, the example still works.

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