When something goes wrong with a patient or a med

When the new EHR is missing old information

A blank field after go-live isn't data. How to chart what's missing, where you got it instead, and who you told.

6 min read built on 0 cases updated 2026-09-20

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

Maya reacting to this topic
All sections

It's go-live weekend, or a migration went bad, or an interface broke. You open the chart and the prior orders, MAR history, allergy list or old notes aren't there. The meds are still due. You still have to follow orders and chart care. So you chart three things: what was missing, where you got the information instead, and who you told.

Key points

  • A blank field doesn't tell you anything. An empty allergy list or MAR only means the data didn't come across. It doesn't mean no allergies, and it doesn't mean no doses given.
  • Check with a live source and name it in the chart. That can be the patient, family, pharmacy fill history, a transfer sheet, the sending facility or the downtime binder. Every fact you reconcile gets a source.
  • Chart what was missing and since when. Keep it short and specific: which screen, which data, and what time you noticed.
  • Notify people, and chart that you did. Call the prescriber for anything that touches orders or doses. Also tell the charge nurse, pharmacy, and IT or the help desk. Write down names, times and read-back.
  • When the data comes back, reconcile it in a labeled late entry. Don't go back and quietly edit earlier notes.

What to write

How it often gets charted What works better
Unable to see old MAR.Pre-go-live MAR history not visible in new EHR as of 0715. Last dose of metoprolol 25 mg PO per transfer MAR from 4 West: 2100 on 10/05. Confirmed with pharmacist J. Ruiz at 0730 by phone. Next dose given 0900 as scheduled.
NKDA. (field was blank after migration)Allergy field empty after migration. Allergies verified verbally with patient: penicillin (hives), sulfa (rash). Entered manually 0745. Pharmacy notified 0750 for profile review.
Orders not showing, waiting on IT.Active orders not displaying since 1400 (interface issue per help desk ticket #48213). Dr. Patel called 1415, current orders read back and confirmed, written on downtime order sheet and placed in chart. Charge RN M. Lee aware.
Home meds continued.Home med list not migrated. Home meds reviewed with patient's daughter (brought bottles): lisinopril 10 mg daily, last taken 10/05 AM; atorvastatin 40 mg nightly, last taken 10/04. List given to Dr. Patel 1030 for reconciliation.
Prior wound notes unavailable.Prior wound documentation not visible in new EHR. Wound assessed 1100: sacral stage 2, 3 x 2 cm, pink base, scant serous drainage. Patient reports dressing last changed yesterday evening. Wound care RN paged 1110 for baseline comparison.
Silently editing the 0900 note once old data appearsLate entry 10/06 1630 for 0900: Legacy MAR now visible. Shows last metoprolol dose 2100 on 10/05, matching transfer MAR used at 0900. No discrepancy.

Template

Chart note: missing data at the time of care

`` [DATE] [TIME] [WHAT WAS UNAVAILABLE, e.g., pre-go-live MAR history / allergy list / active orders / prior notes] not visible in EHR since [TIME FIRST NOTICED]. Information obtained from: [SOURCE: patient / family member name and relation / pharmacy / transfer sheet / sending facility / downtime binder]. Findings: [WHAT YOU CONFIRMED, e.g., last dose of DRUG DOSE ROUTE at TIME; allergies: ALLERGEN (REACTION)]. Action taken: [WHAT YOU DID: given / held / entered manually / used downtime form]. Notified: [NAME, ROLE] at [TIME] by [phone / in person / secure message]. Read-back: [YES/NO]. Response: [WHAT THEY SAID OR ORDERED]. Help desk ticket: [TICKET NUMBER]. [YOUR NAME, CREDENTIALS] ``

Message to charge nurse or unit manager

`` [DATE] [TIME] Patient: [ROOM / MRN, per facility policy for secure messaging] Issue: [WHAT IS MISSING] not displaying in EHR since [TIME]. Impact on care: [e.g., scheduled meds at TIME cannot be checked against prior doses / allergy profile blank]. Interim plan: [SOURCE USED TO VERIFY], prescriber [NAME] notified at [TIME], [DOWNTIME FORM / MANUAL ENTRY] in use. Help desk ticket: [TICKET NUMBER]. Status at time of message: [OPEN / ESCALATED]. Other patients possibly affected: [YES: LIST / UNKNOWN]. [YOUR NAME, CREDENTIALS, EXTENSION] ``

Safety event / downtime report

`` Date and time identified: [DATE] [TIME] Unit: [UNIT] System affected: [EHR MODULE OR INTERFACE, e.g., MAR history, allergy migration, order interface] Description: [WHAT WAS MISSING OR WRONG], first noticed when [WHAT YOU WERE DOING, e.g., preparing 0900 meds]. Patients affected: [NUMBER / IDENTIFIERS PER POLICY] Interim measures: [SOURCE USED TO VERIFY], [DOWNTIME FORMS USED], [MANUAL ENTRIES MADE]. Notifications: [NAME, ROLE, TIME] for each: prescriber, charge nurse, pharmacy, help desk. Help desk ticket: [TICKET NUMBER] Patient impact observed: [NONE OBSERVED / DESCRIBE FACTUALLY] Status at time of report: [UNRESOLVED / RESOLVED AT TIME] Reported by: [YOUR NAME, CREDENTIALS] ``

Late entry once the data reappears

`` Late entry [DATE] [TIME] for care documented at [ORIGINAL TIME]: [WHAT DATA IS NOW AVAILABLE] now visible in EHR. Compared with information used at [ORIGINAL TIME] from [SOURCE]: [MATCHES / DISCREPANCY: DESCRIBE]. [IF DISCREPANCY: Prescriber NAME notified at TIME. Response: WHAT THEY SAID OR ORDERED.] [YOUR NAME, CREDENTIALS] ``

Words to avoid

Word or phrase Why it hurts Use instead
NKDA (unverified)Turns a missing field into a clinical factAllergies verified with [source]: plus the list, or Allergies not yet verified, [what you did]
per old chartWhich chart? The old system, paper, another facility?Name the source: per transfer MAR from 4 West, per pharmacy fill history
system error / IT issue (alone)Says nothing about careWhat was unavailable, since what time, ticket number, who you notified
unable to verify (and then nothing)Reads like you stopped thereUnable to verify in EHR; verified with [source] at [time]
home meds continuedNo list, no source, no last doseList each med with its source and last dose time
as usual / per routineThe new system has no routine on record yetWrite the actual dose, time, and the order it follows

Where it goes wrong

The most common mistake is a note that only says the system failed: Unable to view MAR. IT aware. It's true, but it skips the part that matters. Someone reading it later — the next shift, pharmacy, a reviewer months from now — can't tell when the last dose went in. They can't tell how you decided to give or hold the next one, or who agreed.

The second problem is quieter. Some migrated records show an empty allergy field. Some default to NKDA. Some show a MAR with no history before go-live. The next prescriber or the next nurse reads that blank as a fact. That's how a data problem becomes a care decision: someone acts on missing information because the screen looked complete.

So your note needs three things the system can't give you: what was missing, what you used instead, and who knows about it.

Bottom line

A blank screen isn't a fact. Write down what was missing, where you got the information instead, and who you told.

What this rests on

No published decision turned up for this question — we looked, and the searches are in the record. So this article stands on published guidance and on how the question is asked on the floor, not on a court opinion. That is a weaker footing than the rest of the guide, and you should know it before you rely on it. The decisions behind the other articles are all in one place.

From nurses online

Quoted as written. Opinion, not a source.

Other guides

Advice, not law.