shift is wild

When it goes sideways

When the dose Isn't there to give

The drawer is empty and pharmacy isn't answering. Here's how to chart it so the gap doesn't end up with your name on it.

8 min read built on 6 full opinions updated 2026-09-30

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

Maya reacting to this topic

It's 0900. The order is active, and the drawer or pocket for that med is empty. Pharmacy never sent it, it's out of stock, or the dispensing cabinet has none. Your note has to show a supply problem that you noticed, reported and followed up on. Nobody reading it later should be able to mistake it for a dose someone forgot.

The short version

  • Don't leave the MAR slot blank, and don't sign it off. Mark the dose not given and write the reason: the drug wasn't there, and here's where you looked.
  • Name who you told. Pharmacy, prescriber, charge nurse. Put each one in the note with the time you reached them and what they said.
  • Write the plan. What happens next? A STAT send, a substitute, a new time, or holding until the provider decides.
  • Hand it off. Still open at shift change? Tell the next nurse, then chart that you did.
  • Close the loop. When the drug shows up and you give it, chart the actual time and tie it back to the delay.

What goes wrong

The usual mistake isn't a false entry. It's a thin one.

A MAR slot with just NA or not given tells a later reader one thing: the dose didn't happen. It doesn't say why. It doesn't say whether anyone did anything about it. Put a few days of those in a row and a pharmacy that never delivered looks exactly like a nurse who kept skipping the med. The reader can't tell which.

Mixed entries are worse. Say one shift writes NA, the next initials the dose as given, and the one after that writes NA again. Now the MAR says the drug was on the unit that middle day. Anyone reading it later will take that initial as proof the supply problem was fixed, even if it wasn't. If you initial a whole column after passing a med cup, you can end up with a record that says the opposite of what happened.

The other trap is fixing the chart instead of the order. When a med keeps not showing up, you'll be tempted to decide it must have been discontinued and note that on the MAR. If there's no order in front of you, that isn't documentation. It's a guess that looks like a decision.

It is not hypothetical

State of Iowa v. Michael Buman, Court of Appeals of Iowa, 2020. Read the opinion

A resident's clozapine wasn't in the two-week supply the pharmacy delivered. On the first night, an RN marked it NA (not available) on the MAR and told the day nurse that pharmacy needed to be contacted. The next night it was still missing. She marked it NA again and passed that on at shift change. The following day, a medication aide initialed the MAR as if the clozapine had been given.

The day after that, a different RN searched both med carts and the nurse's station. Nothing. He wrote DC'ed on the MAR, believing the discontinuation had never been entered. He later testified that the pharmacy couldn't be reached overnight and the resident's chart was locked away during night shift. The resident was later hospitalized. The facility administrator took the aide's initials as proof the drug had been delivered. The opinion notes there was no evidence the pharmacy delivered clozapine during those days.

The RN was charged and convicted of a misdemeanor. The Court of Appeals reversed the conviction and sent the case back. At trial, the jury was shown the Iowa Board of Nursing standard. It says that when an order isn't carried out, the RN's accountability includes:

"Timely notification of the physician who prescribed the medical regimen that the order(s) was not executed and reason(s) for same."

Here's what matters for your charting. Every MAR entry from that week ended up being read as evidence of what was physically on the unit. Now look at the first nurse. Both nights, she marked the drug not available and told the next shift. That's the part of the record that clearly showed what she knew and what she did.

Paige v. Secretary of Health and Human Services, U.S. Court of Federal Claims, 2021. Read the decision

This one isn't about medication supply. It's here because it shows how much weight a form written at the time can carry against someone's memory later. A nurse said she got her flu shot on a different date from the one on her vaccine form. The special master wrote:

"I find that petitioner more likely than not received her vaccination on November 11, 2015 as reflected in her contemporaneous vaccine administration form."

What you write in the moment can become the version everyone relies on. It can outweigh your own memory of what happened.

What to write instead

How it often gets charted How it should read
NANot given. Metoprolol 25 mg not in ADC or patient bin at 0900. Pharmacy called 0905, spoke w/ J. Lee RPh, dose being sent from main pharmacy, ETA 30 min.
Not given - waiting on pharmacyNot given at 0800. Vancomycin 1 g IV not delivered; not in unit fridge. Pharmacy called 0810, bag in compounding, ETA 0930. Dr. Patel paged 0815 re: delay, OK to give on arrival. Will chart actual time.
Given (initialed with the rest of the 2100 meds)If the drug wasn't there, don't initial that slot. Chart it as not given with the reason, even if every other med in the cup was given.
DC'd (no order found, med keeps not showing up)Levetiracetam 500 mg not available 3rd consecutive dose per MAR. No DC order found in chart/eMAR. Pharmacy closed overnight; on-call pharmacist paged 2210, no callback by 2240. On-call provider Dr. Kim paged 2245, advised [instruction]. Charge RN M. Ortiz notified.
HeldSave Held for a clinical decision, like BP too low or NPO. For a supply problem, write Not given - medication not available plus the details.
Given lateMetoprolol 25 mg given 1050 (scheduled 0900). Delay d/t med not in ADC; delivered by pharmacy 1040. See 0905 note. HR 88, BP 132/80 prior to dose.
Oncoming RN awareReport given to K. Singh RN at 1900: clozapine 100 mg not available for 2100 dose, pharmacy re-sending, provider aware.

Words that do the damage

Word or phrase Why it causes trouble Use instead
NA aloneCould mean not available, not applicable or not administered. No reason, no action.Not given - not available plus where you looked and who you called
HeldReads like a clinical judgment you madeNot given - not available, unless you really held it for a clinical reason
MissedSounds like somebody forgotNot given - [reason]
DC'd / DC'edReads as a change to the orderOnly when a discontinue order exists. Otherwise write No DC order found; provider paged
Pharmacy awareDoesn't say who, when or what they saidPharmacy called [time], spoke w/ [name], [what they said]
MD awareSame problemDr. [name] notified [time] via [page/call], orders: [instruction or none]
Will f/uA promise with no time and no ownerWill recheck ADC at [time] / Passed to [name] RN at report
Unable to giveCould be refusal, NPO, no IV access or no drugName the actual reason

What the guidance says

The policy that applies to you is your facility's own: its not-given codes, its late-dose windows, its rules for reporting to pharmacy. Check it.

Copy this

MAR comment for the not-given dose

`` Not given - medication not available. [DRUG] [DOSE] [ROUTE] not found in [ADC / patient bin / med cart / unit fridge] at [TIME]. Pharmacy contacted [TIME], spoke with [NAME]. [WHAT PHARMACY SAID, e.g. re-sending, ETA TIME / out of stock]. Prescriber notified - see note [TIME]. ``

Nursing note

``` [DATE] [TIME] Scheduled [DRUG] [DOSE] [ROUTE] due at [SCHEDULED TIME] not available on unit. Checked [ADC, patient bin, med cart, unit refrigerator, returns bin]. Not located.

[TIME] Pharmacy contacted by [phone / page], spoke with [NAME, RPh]. Pharmacy reports [WHAT THEY SAID - e.g. dose not yet verified / out of stock / being compounded / sent to wrong unit]. Expected delivery [TIME or UNKNOWN].

[TIME] [PROVIDER NAME] notified by [phone / page / secure message] that dose not given due to supply delay. Provider response: [ORDERS RECEIVED - e.g. give on arrival / substitute DRUG DOSE / hold until next scheduled dose / no new orders].

[TIME] Charge nurse [NAME] notified.

Patient assessment at time of missed dose: [RELEVANT VITALS OR FINDINGS - e.g. BP, HR, glucose, pain score, mental status].

Plan: [WHAT HAPPENS NEXT - e.g. recheck ADC at TIME / give on arrival and chart actual time / reassess at TIME]. ```

Follow-up note when the dose arrives

`` [DATE] [TIME] [DRUG] [DOSE] [ROUTE] received from pharmacy at [TIME]. Administered at [TIME] (originally scheduled [SCHEDULED TIME]) per [PROVIDER NAME] instruction at [TIME]. Delay due to medication not available on unit - see note [TIME]. Pre-dose [VITALS / RELEVANT FINDINGS]. Next dose [TIME as scheduled / retimed to TIME per pharmacy/provider]. ``

Message to the provider

`` [PATIENT NAME / ROOM / MRN]. Scheduled [DRUG] [DOSE] [ROUTE] at [TIME] not given - medication not available on unit. Pharmacy ([NAME]) reports [REASON / ETA]. Current [RELEVANT VITALS OR FINDINGS]. Please advise: give on arrival, substitute, or hold to next scheduled dose. [YOUR NAME], RN, ext. [NUMBER]. ``

Handoff line, when it's still open at shift change

`` Report given to [ONCOMING RN NAME] at [TIME]: [DRUG] [DOSE] not given at [TIME] - not available. Pharmacy contacted [TIME], [STATUS / ETA]. Provider [NAME] notified [TIME], orders: [ORDERS]. Outstanding: [WHAT STILL NEEDS TO HAPPEN]. ``

Safety or incident report, if your facility wants one for supply delays

`` Date/time identified: [DATE] [TIME] Unit / location: [UNIT] Medication: [DRUG] [DOSE] [ROUTE] [FREQUENCY] Scheduled time: [TIME] What happened: Scheduled dose not available on unit. Locations checked: [LIST]. Medication [was not in last pharmacy delivery / ADC pocket empty / out of stock per pharmacy / OTHER]. Doses affected: [NUMBER] ([LIST DATES/TIMES]) Notifications: Pharmacy [NAME, TIME]. Provider [NAME, TIME]. Charge nurse [NAME, TIME]. Provider orders received: [ORDERS or NONE] Outcome: [Dose given at TIME / dose not given / substitute given / pending] Patient status: [RELEVANT FINDINGS or NO CHANGE NOTED] Reported by: [YOUR NAME, CREDENTIALS] ``

If you remember one thing

When the drug isn't there, write down where you looked, who you told and what happens next. And never initial a dose you didn't give.

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.

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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