shift is wild

When it goes sideways

When the patient says the charted pain dose was not given

A controlled med is charted, the patient disagrees, and the chart wants a villain. Write the note like you still want a license.

8 min read built on 6 full opinions updated 2026-09-19

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

Denise reacting to this topic

The MAR says a controlled pain med was given. The patient says they did not get it, or their pain is still severe. Don’t try to solve the whole thing in one note. That is not the job.

Your job is to document what you know, assess the patient, avoid a duplicate dose, and get the right people involved.

The short version

  • Assess the patient now: pain score, location, sedation, respiratory status, vitals, and visible distress.
  • Chart the patient’s statement as a statement. Not as proof that the MAR is wrong.
  • Compare the eMAR, dispensing record, waste record, and controlled-substance count per facility process.
  • Notify the charge nurse and provider promptly, especially before giving another opioid dose.
  • Do not accuse, erase, overwrite, or document blame. Use the facility occurrence report outside the chart if required.

What goes wrong

The usual mistake is writing the conclusion before you have the facts.

Example: Med charted but not given or possible diversion by prior nurse.

That may feel direct. It is also a problem. You just skipped several possibilities: the dose may have been given but not worked, given late, documented under the wrong time, wasted incorrectly, scanned incorrectly, or entered on the wrong patient.

With controlled meds, the chart, dispensing cabinet, waste record, and count all need to line up. If they do not, your note should show the discrepancy and what you did next. Not your guess about why it happened.

Another mistake: giving another full opioid dose just because the patient says they did not get the first one. The patient may be telling the truth. The MAR still shows an administered dose. Until the discrepancy is clarified, or the provider gives you a safe plan, treat it as two problems at once: pain control and medication safety.

It is not hypothetical

  • Henning v. Avera McKennan, South Dakota Supreme Court, 2020. https://www.courtlistener.com/opinion/9507894/henning-v-avera-mckennan/ The hospital tracked controlled-substance removals, administration documentation, waste, and unaccounted medication. The nurse was terminated after documentation errors and inability to account for controlled substances; the South Dakota Supreme Court affirmed summary judgment for the hospital.
  • KELLY-KOFFI v. Wesley Medical Center, District Court, D. Kansas, 2003. https://www.courtlistener.com/opinion/2578116/kelly-koffi-v-wesley-medical-center/ The record involved narcotic documentation discrepancies, chart review, and termination. The court granted summary judgment for the employer.
  • Gabriel v. County of Herkimer, District Court, N.D. New York, 2012. https://www.courtlistener.com/opinion/8718656/gabriel-v-county-of-herkimer/ The court record included complaints that medications were wrong, a MAR, a narcotics list, and security-log inconsistencies. This is the type of record where clear medication documentation and follow-up matter.

What to write instead

Instead of this Write this
Patient claims 2100 Dilaudid was not given. Prior nurse must have charted it wrong.2135 Patient awake in bed, guarding abdomen, reports pain 9/10. Patient states: I did not receive the 2100 hydromorphone dose. eMAR reviewed and shows hydromorphone 0.5 mg IV documented at 2102 by [NAME]. This RN did not observe that administration. RR 18, SpO2 96 percent on room air, sedation score 1. Charge RN [NAME] notified at 2140. Provider [NAME] notified at 2145 for pain plan and medication discrepancy review.
Med error. Oxycodone charted but patient did not get it.1840 On assuming care, patient reports oxycodone dose due earlier was not received. eMAR shows oxycodone 5 mg PO documented as administered at 1748 by [NAME]. Patient reports pain 8/10 in right hip. BP 132/78, HR 92, RR 16, alert and oriented. Charge RN notified. Controlled-substance reconciliation requested per unit process. Awaiting provider direction before additional opioid dose.
Patient still screaming after morphine. Wants more narcotics.1515 Pain reassessment completed 45 minutes after eMAR-documented morphine 2 mg IV at 1430. Patient reports pain remains 10/10 in left lower quadrant. Patient crying, knees flexed, abdomen tender to light palpation. RR 20, SpO2 97 percent, sedation score 1. Provider notified of uncontrolled pain after ordered PRN dose. No additional opioid given without new order.
Gave another dose because patient said she did not get the first one.1005 Patient states prior hydromorphone dose was not received. eMAR shows hydromorphone 0.4 mg IV documented at 0930. Due to existing administered entry, no repeat opioid dose given at this time. Charge RN and provider notified. Patient repositioned, heat pack applied per order, call light in reach. Pain to be reassessed after provider plan.
Possible diversion by night nurse.0710 Controlled medication discrepancy identified during review of hydromorphone 1 mg/mL. eMAR shows dose administered at 0645. Dispensing record and remaining count do not match expected count. Charge RN [NAME] and pharmacy [NAME] notified. Reconciliation in progress per facility policy. Patient assessed for pain and sedation.

Words that do the damage

Avoid Why Use instead
LyingYou’re accusing the patient instead of charting clinical facts.Patient states dose was not received
Drug-seekingYou’re labeling the patient instead of assessing pain and safety.Patient reports pain [NUMBER]/10 and requests pain medication
DiversionThat is an investigation conclusion. Don’t put it in a bedside note unless it has been formally determined.Controlled-substance discrepancy identified
Nurse charted falselyYou’re accusing another staff member without verification.eMAR shows dose documented by [NAME]; this RN did not observe administration
Med errorIt may be true later. Often, you do not know that at the time of the note.Medication discrepancy noted; review initiated
No relief, probably fakingUnsupported. Dismissive. Not useful.Patient reports pain remains [NUMBER]/10; observed [OBJECTIVE FINDINGS]
Incident report completedFacility reports usually stay outside the medical record.Charge RN notified; follow-up per facility policy

What the guidance says

  • Medication administration belongs on the MAR or eMAR. If there is a medication-documentation problem, fix it through the medication documentation workflow. Don’t hide it in a narrative note. (health.maryland.gov, openstax.org)
  • If a medication was not given, the MAR should show that it was not given using the system or paper process your facility requires. (cstcernerhelp.healthcarebc.ca.htm), med.libretexts.org/11:_Principles_of_Medication_Administration/11.03:_Documentation_of_Medication_Administration))

Copy this

Chart note when patient says the dose was not received

```text [DATE] [TIME] Patient assessed after report of uncontrolled pain and concern about medication administration. Patient alert and oriented to [LEVEL]. Patient states: [PATIENT WORDS ABOUT NOT RECEIVING DOSE]. Pain [NUMBER]/10 at [LOCATION], described as [QUALITY]. Objective findings: [GUARDING/GRIMACING/RESTLESSNESS/OTHER]. Vital signs: BP [BP], HR [HR], RR [RR], SpO2 [SPO2], sedation score [SCORE].

eMAR reviewed. eMAR shows [MEDICATION] [DOSE] [ROUTE] documented as administered at [TIME] by [NAME]. This RN did not observe that administration. No additional opioid dose given at this time pending clarification and provider direction.

Charge RN [NAME] notified at [TIME]. Provider [NAME] notified at [TIME] of patient report, current pain score, vital signs, sedation status, and eMAR entry. Controlled-substance reconciliation initiated per facility policy by [NAME/ROLE]. Patient updated on plan. Pain and sedation to be reassessed by [TIME]. ```

Chart note when the dose was given but pain remains severe

```text [DATE] [TIME] Pain reassessment completed after eMAR-documented [MEDICATION] [DOSE] [ROUTE] administered at [TIME]. Patient reports pain remains [NUMBER]/10 at [LOCATION], described as [QUALITY]. Objective findings: [GUARDING/GRIMACING/MOANING/RESTLESSNESS/OTHER]. Vital signs: BP [BP], HR [HR], RR [RR], SpO2 [SPO2], sedation score [SCORE]. No signs of excessive sedation noted at this time.

Nonpharmacologic measures provided: [REPOSITIONING/ICE/HEAT/DIM LIGHTS/RELAXATION/OTHER]. Provider [NAME] notified at [TIME] that pain remains severe after ordered PRN medication. New orders or plan: [ORDERS/NO NEW ORDERS/CONTINUE CURRENT PLAN]. Patient updated. Will reassess pain, sedation, and respiratory status by [TIME]. ```

Message to charge nurse or supervisor

``text [DATE] [TIME] Notified [CHARGE RN/SUPERVISOR NAME] that patient [PATIENT NAME/MRN] reports [MEDICATION] dose documented on eMAR at [TIME] was not received. Current pain [NUMBER]/10. eMAR shows [MEDICATION] [DOSE] [ROUTE] administered by [NAME]. This RN did not observe the documented administration. Current assessment: BP [BP], HR [HR], RR [RR], SpO2 [SPO2], sedation score [SCORE]. Requested controlled-substance reconciliation and guidance per facility policy. ``

Medication discrepancy or occurrence report

``text [DATE] [TIME] Medication discrepancy reported for patient [PATIENT NAME/MRN]. eMAR shows [MEDICATION] [DOSE] [ROUTE] documented as administered at [TIME] by [NAME]. Patient stated at [TIME] that the dose was not received. Current assessment at [TIME]: pain [NUMBER]/10, BP [BP], HR [HR], RR [RR], SpO2 [SPO2], sedation score [SCORE]. This RN did not observe the documented administration. Charge RN [NAME] notified at [TIME]. Provider [NAME] notified at [TIME]. Controlled-substance count/reconciliation status: [WHAT WAS FOUND OR PENDING]. Additional actions taken: [ACTIONS]. ``

If you remember one thing

Chart what you know right now, not who you think is at fault.

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.

  • If I encounter such a situation, I usually write (or place a sticker saying same) "check dosage" on the card, to alert nurses that ordered dose and available dose differ. ... Specializes in Critical Care.

    MAR how should it read? - Patient Medications allnurses

  • MD wasn't worried, came to floor 10-15 mins later for roundings, assessed the patient and cleaned up PRN pain med list and gave me a one time order for Benadryl IV dose I actually administered. My preceptor told me there was nothing more that needed to be done (I asked about filing an incident

    Med error...what to do? - General Nursing - allnurses allnurses

  • I would have wrote: resident states "my Meds werent given to me all day!" ... I would certainly put any quotes in context as well-such as body language, pacing, shaking fists, and that MAR was checked, prior nurse spoken to and verifies patient received medications, staff has noted signs o

    Is there a proper way to chart what a patient/resident says? - General Nursing Support allnurses

  • I like all your guys' responses on how and what to chart... but would you chart that on all of your pts??? I was taught to chart: "Pt. alert and oriented (or confused), able tomake needs known. No c/o pain or discomfort. No signs of distress noted. Respirations even and unlabored. All need

    Charting question.. - Patient Safety Issues - allnurses allnurses

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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