Everyday charting

Charting the medication your patient brought from home

The bag of pill bottles at admission, and the four things the chart needs so the next nurse isn't left guessing.

7 min read built on 0 cases updated 2026-11-02

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

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Your patient shows up with a bag of pill bottles, a rescue inhaler and an insulin pen. Before you use any of it, the chart has to say four things: what each item is, who confirmed it, where it went, and whether the patient may use it on their own. Miss one and the next nurse has to guess.

Key points

  • Identify each item separately. Write the drug, strength, form, and count or remaining volume. Then the label: pharmacy, Rx number, fill date, prescriber. And what shape the container is in.
  • Name who checked it and how. Write their name, role and the time. Then what they checked it against: the label, the pill imprint, the pharmacy, or the active order.
  • Say where it went. It went home with a named person, or pharmacy or the unit secured it and gave a receipt, or it stays at the bedside under an order. Pick one. Don't mix them.
  • Self-administration needs an order, and your policy decides whether it's allowed at all. Some facilities allow it with an order. Some don't allow it, period. Chart which rule applied and who wrote the order.
  • Each dose still goes on the MAR. That includes the doses the patient took themselves. Use your facility's self-med notation and say whether you watched or the patient told you.

What to write

Identification

How it often gets charted How it should read
Pt brought home meds.Pt arrived with 3 home medication containers. Listed individually below with label details and counts.
Lisinopril from home.Lisinopril 10 mg tablets, pharmacy label CVS #4471, Rx 0938821, filled 09/14, prescriber Dr. A. Patel. 22 tablets counted. Container sealed label intact, tablets match label description.
Insulin pen.Insulin glargine pen, 100 units/mL, labeled with pt name, pharmacy label Rx 551203. Approx 180 units remaining per dose window. Pen cap present, no visible damage, expiration on pen 03/2027.
Unlabeled pills in baggie.Plastic bag containing 6 white round tablets, no label. Pt states they are Tylenol. Not identified. Not used. Sent to pharmacy for identification per policy.

Who checked it

How it often gets charted How it should read
Verified by pharmacy.Home supply of levetiracetam 500 mg identified by J. Ruiz, PharmD, at 1420 by imprint and label. Matches active order. Approved for use per pharmacy.
Checked with charge RN.Count of oxycodone 5 mg (14 tablets) confirmed with M. Chen, RN, charge nurse, at 1510. Both signatures on controlled substance home med form.

Where it went

How it often gets charted How it should read
Meds sent home.Home metformin, atorvastatin and lisinopril (containers as listed above) given to pt's daughter, Ana Lopez, at 1630. Pt aware. Daughter signed belongings form.
Meds locked up.Home oxycodone 5 mg, 14 tablets, sealed in bag #22871 and sent to pharmacy at 1530. Pharmacy receipt in chart. Pt given copy.
Inhaler at bedside.Albuterol HFA (pt's own) kept at bedside per order by Dr. Kim, 11/02 1400. Pt instructed to tell RN after each use.

Self-administration while admitted

How it often gets charted How it should read
Pt took own inhaler.1815: Pt reports taking 2 puffs albuterol (own inhaler, bedside per order) for SOB at 1805. RR 22, SpO2 94% RA, lungs with expiratory wheeze bilat. Recorded on MAR as PRN, self-administered, pt reported.
Pt gave own insulin.0745: Pt self-administered insulin glargine 24 units SC L abdomen using own pen, per self-admin order. Dose and pen dial observed by this RN. Recorded on MAR with self-med notation.
Pt taking own pills, ok per pt.Found pt's own bottle of amlodipine at bedside at 0930. Pt states took 1 tab at 0700. No order for self-administration or home supply use. Bottle secured per policy. Dr. Kim notified 0940 of possible dose taken; hospital 0900 dose held per instruction.

Template

Admission: home meds sent home with family

[DATE] [TIME]
Pt arrived with [NUMBER] home medication containers. Each listed below:
1. [DRUG] [STRENGTH] [FORM], label [PHARMACY], Rx [RX NUMBER], filled [FILL DATE], prescriber [PRESCRIBER]. Count: [COUNT OR VOLUME]. Condition: [LABEL INTACT / DAMAGED / UNLABELED].
2. [DRUG] [STRENGTH] [FORM], label [PHARMACY], Rx [RX NUMBER], filled [FILL DATE], prescriber [PRESCRIBER]. Count: [COUNT OR VOLUME]. Condition: [CONDITION].
3. [REPEAT AS NEEDED]
Items reviewed with [NAME, ROLE] at [TIME].
Home medication list provided to pharmacy for reconciliation at [TIME].
All items above given to [NAME], [RELATIONSHIP TO PT], at [TIME]. [NAME] signed belongings form. Pt informed that hospital will supply ordered medications during stay.
[YOUR NAME], [CREDENTIALS]

Admission: home meds secured by pharmacy or unit

[DATE] [TIME]
Pt's own supply of the following secured per policy:
1. [DRUG] [STRENGTH] [FORM], label [PHARMACY], Rx [RX NUMBER], filled [FILL DATE]. Count: [COUNT].
2. [REPEAT AS NEEDED]
Count of controlled substances confirmed with [NAME, ROLE] at [TIME]. Both signatures on [FORM NAME].
Items sealed in bag/envelope #[NUMBER] and sent to [PHARMACY / LOCATION] at [TIME]. Receipt #[RECEIPT NUMBER] placed in chart. Copy given to pt.
Pt informed that items will be returned at discharge per policy.
[YOUR NAME], [CREDENTIALS]

Patient using own medication under an order

[DATE] [TIME]
Order for pt to use own supply of [DRUG] [STRENGTH] [FORM] written by [PRESCRIBER] on [ORDER DATE] at [ORDER TIME]. [SELF-ADMINISTRATION ALLOWED / NURSE TO ADMINISTER FROM PT SUPPLY].
Item identified by [NAME, ROLE] at [TIME] by [LABEL / IMPRINT / PHARMACY REVIEW]. Matches active order.
Stored at [BEDSIDE / MED ROOM / PT BIN].
Pt instructed to tell RN after each use. Pt stated understanding.

Dose entry:
[TIME]: [DRUG] [DOSE] [ROUTE] [SITE IF INJECTION], self-administered by pt. [OBSERVED BY THIS RN / PT REPORTED, TAKEN AT TIME]. Pre-dose: [VITALS OR ASSESSMENT]. Post-dose: [RESPONSE]. Recorded on MAR with [FACILITY SELF-MED NOTATION].
[YOUR NAME], [CREDENTIALS]

Found a home med with no order

[DATE] [TIME]
Found [DRUG] [STRENGTH] [FORM], pt's own supply, at [LOCATION]. No active order for use of pt's own supply or self-administration.
Pt states last dose taken at [TIME / UNKNOWN].
Item secured per policy at [TIME], [WHERE].
[PRESCRIBER] notified at [TIME] of possible dose taken. Instruction received: [INSTRUCTION, E.G. HOLD SCHEDULED DOSE / GIVE AS ORDERED].
Charge RN [NAME] informed at [TIME].
[YOUR NAME], [CREDENTIALS]

Words to avoid

Word or phrase Why it causes trouble Use instead
home medsIt's a category, not a list. Nobody can tell what or how many.Drug, strength, form and count for each item
own medsSame issue, plus it hides whether there's an orderPt's own supply of [drug], use approved by [name/order]
verifiedBy whom? Against what?Identified by [name, role] by [label / imprint / pharmacy]
pt awareAware of what? Who told them?Pt told by this RN that [X]. Pt stated understanding.
at bedsideCould mean approved, forgotten or hiddenAt bedside per order [prescriber, date, time] or found at bedside, no order
sent homeNo recipient, no time, no listGiven to [name, relationship] at [time], items listed above
took ownDid you watch, or were you told?Observed by this RN or Pt reports

Home meds at bedside, no list, no count

The classic entry is Home meds at bedside. No list, no count, no order, no name. This is what happens next:

  1. Night shift sees an inhaler on the tray table. Was it approved? They can't tell. So they can't tell whether the patient's puffs count as doses.
  2. The patient takes their own metoprolol at 0800, same as at home. Day shift gives the hospital metoprolol at 0900. The chart has no trace of the first dose.
  3. At discharge the family asks where the rest of the oxycodone went. Nobody counted it on admission. Nobody can answer.

The real problem is that a home med sits outside the usual loop. Pharmacy dispenses hospital stock, then it gets scanned and counted automatically. The patient's own bottle gets none of that unless a nurse writes it down. Your admission note is the only record the item exists. If the note is vague, nobody is tracking that item.

Bottom line

For every home med, write what it is, who checked it, where it went and who gave each dose. Then the next nurse doesn't have to guess.

Official guidance

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.

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