When something goes wrong with a patient or a med
When the patient says the new med is making things worse
A patient blames the new med. Your note has to show you heard it, checked it, called someone, and followed through.
7 min read built on 2 full opinions updated 2026-10-14
Written by a med-surg RN, ten years, day shift. Why there is no name on it · How this guide is made
All sections
You started a new drug or changed a dose. Now the patient says they feel worse. Your note needs four things, in this order: what they said, what you found, who you told, and what happened next. If you leave one out, whoever reads the chart next can't tell whether the complaint was heard or ignored.
Key points
- Write down the patient's own words (in the real chart, those go in quotation marks). Add the drug, the dose and the time of the last dose.
- Next to that, chart what you saw and measured: vitals, a focused assessment, and how it compares to their baseline.
- Name who you notified, when, and how: phone, page or in person. Then chart what they told you.
- Chart what changed. Dose held, dose lowered, new order, or no new orders, continue to monitor with a time for your next check.
- Close the loop. Reassess, and put it in handoff so the next shift knows it's still open.
What to write
| How it often gets charted | What to chart instead |
|---|---|
Pt c/o feeling bad on new med. | 1410: Pt states, [patient's words in quotes], since first dose of lisinopril 10 mg PO at 0900. Reports lightheadedness when standing. Denies chest pain, SOB. |
Dizzy. MD aware. | 1420: BP 92/58 sitting, 78/50 standing, HR 104 standing (baseline BP 138/82 this AM). Dr. Patel paged 1422, called back 1430. Reported pt complaint, orthostatic vitals, time of dose. Read-back done. |
Will monitor. | 1435: Order received from Dr. Patel: hold lisinopril 1700 dose, recheck orthostatics at 1530, call if SBP <90 standing. Fall precautions reinforced, bed alarm on, pt instructed to call before getting up. Pt verbalized understanding. |
Pt anxious about meds, reassured. | Pt asked if new sertraline is causing her racing heart. Explained common early side effects per drug reference. HR 88 regular. Notified Dr. Kim at 1015 per pt request. No new orders, plan to reassess at next visit. Pt states she wants to continue for now. |
Tolerating meds well. (auto-filled at 1600) | Uncheck or edit the template. 1600: Nausea reported at 1300 improved after ondansetron 4 mg IV at 1320. Pt rates nausea 2/10, was 7/10. Tolerated clear liquids. |
Refused metformin. | 0800: Pt declined metformin 500 mg, states it causes diarrhea since dose increase 3 days ago. Reports 4 loose stools yesterday. Abdomen soft, nontender. Dr. Lee notified 0815 via secure message. Response 0840: hold, will review dosing on rounds. |
The pattern in every row: each complaint gets a time, a link to a specific dose, a measurement, a named person and a result.
Template
Nursing note
[DATE] [TIME]
S: Pt states: [PATIENT'S EXACT WORDS, IN QUOTATION MARKS IN THE CHART].
Onset: [WHEN SYMPTOM STARTED] after [DRUG] [DOSE] [ROUTE], started/changed on [DATE]. Last dose given [TIME].
Pt rates [SYMPTOM] [X]/10. Pt denies [PERTINENT NEGATIVES].
O: VS: BP [ ], HR [ ], RR [ ], SpO2 [ ], Temp [ ]. Baseline this shift: [BASELINE VALUES].
Focused assessment: [FINDINGS, e.g., ORTHOSTATICS, SKIN, NEURO, GI].
Relevant labs: [LAB, VALUE, TIME] or none pending.
A/Notification: [PROVIDER NAME, ROLE] notified at [TIME] via [PHONE / PAGE / SECURE MESSAGE / IN PERSON].
Reported: pt statement, findings above, time of last dose.
Provider response at [TIME]: [ORDERS RECEIVED, READ BACK AND VERIFIED] OR [NO NEW ORDERS. PLAN PER PROVIDER: ...].
P: Next dose of [DRUG] due [TIME]: [HELD PER ORDER / GIVEN PER ORDER / DOSE CHANGED TO ...].
Safety measures: [FALL PRECAUTIONS, BED ALARM, ETC.].
Education: explained [WHAT YOU EXPLAINED]. Pt response: [WHAT PT SAID OR DID].
Reassess [WHAT] at [TIME].
[REASSESSMENT TIME]: [FINDINGS]. Pt states [WORDS]. [FURTHER ACTION OR NONE NEEDED].
[YOUR NAME, CREDENTIALS]Call or page to the prescriber
This is [YOUR NAME], RN, on [UNIT], calling about [PATIENT NAME], room [ROOM], DOB [DOB].
Situation: Pt reports [SYMPTOM] since [DRUG] [DOSE] was [STARTED / CHANGED] on [DATE]. Last dose at [TIME]. Next dose due [TIME].
Background: Admitted for [REASON]. Relevant history: [ALLERGIES, RENAL/HEPATIC FUNCTION, OTHER NEW MEDS].
Assessment: VS [VALUES], baseline [VALUES]. Findings: [FINDINGS]. Pt rates [SYMPTOM] [X]/10.
Request: Do you want the [TIME] dose held, changed, or given? Any labs or parameters you want?
Read-back of orders: [ORDERS AS READ BACK].Handoff line
[DRUG] [DOSE]: started/changed [DATE]. Pt reported [SYMPTOM] at [TIME].
[PROVIDER] notified [TIME]; orders: [HOLD / NEW DOSE / PARAMETERS / NONE].
[NEXT DOSE TIME]: [HELD / GIVE IF ...]. Last reassessment [TIME]: [FINDINGS].
Watch for: [WHAT TO WATCH]. Call [PROVIDER] if [PARAMETER].Words to avoid
| Word or phrase | Why it hurts | Use instead |
|---|---|---|
| MD aware | No name, no time, no channel, no response | Dr. [Name] notified [time] via [phone/page/in person]. Response: [orders or none] |
| Tolerating well / no adverse effects | Usually a template, and it contradicts the complaint from the same shift | What you actually found, or leave it blank |
| c/o side effects | Which effect? How bad? | The symptom, when it started, and a rating |
| Will monitor | Monitor what? When? | Recheck [what] at [time] |
| Noncompliant / refused | Sounds like blame and hides the reason | Declined [drug], states [reason] |
| Anxious / drug-seeking / complaining | A label where an observation should be | What the patient said and did |
| Reassured | Tells the reader you calmed them down. Doesn't say what you told them. | Explained [content]. Pt verbalized [response] |
A complaint charted with nothing after it
Most bad notes tell only half the story.
The complaint is charted, but nothing after it. You write Pt c/o dizziness since new BP med at 1400. The next entry is a routine assessment at 1800. You probably called someone, took a BP and talked to the patient. None of it is in the chart. Someone reading it two years later sees a complaint followed by four hours of silence and decides nobody did anything.
The action is charted, but not the reason. Metoprolol held with no explanation looks like a missed dose. Put the complaint and your findings next to it. Otherwise the hold reads like an error.
***MD aware* with nothing else.** Which provider? What time? Phone or page? What did they say? MD aware proves nothing. Anyone could write it about anything.
Boilerplate contradicts the complaint. At 1600 the flowsheet auto-fills tolerating medications well. Your 1400 note says the patient has new nausea since the dose change. Now the record is arguing with itself.
The handoff loses it. A Reddit thread on nursing judgment describes a nurse giving the drug again because nobody passed on that it had been a problem. If the complaint sits in one narrative note and never reaches the handoff or the care plan, the next nurse finds out the hard way.
Bottom line
Next to the patient's words, chart what you found, who you told and when, and what changed.
Official guidance
- With a new drug or a changed dose, check the patient for the effect the drug should have and for its known side effects. Then a new complaint has a baseline to be compared against. (Nursing Skills 2e, RegisteredNursing.org)
- If the patient's condition changes after a med, tell the prescriber. Document both the change and what you did about it. (RegisteredNursing.org, OpenStax)
In court, 2015–2019
What happened in 2 court cases
Tye-Smiley v. Ohio State Univ. Wexner Med. Ctr.: Ohio Court of Claims, 2019. This wrongful death case went to trial. The decision goes through the testimony one clinician at a time, and each of them relies on what their own notes showed. The prison nurse had charted his pain ratings (5 out of 10 one day, 8 on a later day), where the pain was, and that he was using a walker. The nurse practitioner had charted that his pain was getting worse every day, what she found on exam, and her decision to send him out. The part closest to this topic comes from the hospitalist who saw him after admission. Her progress note showed that "Smiley indicated that he thought a dose of prednisone he was given during the orthopedic consultation was causing some of his symptoms", and that she lowered his dose in response. That's the whole chain in one entry: what the patient blamed, what the clinician did, and the reason connecting the two. Years later, each witness could rebuild what happened only from what had been written down. The text we have stops partway through the testimony, so the outcome isn't covered here.
Vivek Goswami, M.D. and Austin Heart, PLLC v. Nancy Jo Rodriguez: Texas Court of Appeals, 3rd District (Austin), 2015. This document is the defendants' appellate brief. So it gives one side's account and says nothing about how the appeal ended. The dispute was over a blood thinner (Pradaxa). One cardiologist ordered it stopped, but the patient kept refilling an earlier prescription. According to the brief, those refills happened "without any communication with Dr. Goswami or Austin Heart." The whole argument comes down to the paper trail of a med change: who knew, and when. Your note answers the same question when you chart who you told and what changed.
Court decisions
Published decisions, linked to CourtListener.
- Tye-Smiley v. Ohio State Univ. Wexner Med. Ctr.
- Vivek Goswami, M.D. and Austin Heart, PLLC v. Nancy Jo Rodriguez
All decisions behind this guide
From nurses online
Quoted as written. Opinion, not a source.
Then I butt in and say, hey, did you ask about XYZ? Bam, now we both know. ... "This is what it's for, these are the worst things to look out for. Here's an information sheet with more info." ... I always tell them the medication name and what it’s for. Certain meds I’ll do side
r/nursing on Reddit: How in depth do you educate patients on medications they are taking? redditAnd truthfully almost every nurse that I've spoken to and have worked with has given their own "nursing" doses either by mistake or intentionally you are not alone. What matters most is that you did the right thing to notify the right people to make sure that ultimately patient harm w
Struggling after med error : r/nursing redditFor example, charting a urine output of 10cc for the hour, “MD notified, awaiting further orders.” I realized that that’s dumb, so now I wait until I get a new order, perform it and then comment “MD notified, 500cc LR bolus ordered and ...
r/nursing on Reddit: What are some things you know/have learned not to chart in nurses not redditAnd ensure you're following guidance ... a new drug to you or the patient, look it up so you can do some patient education and know what to look out for or ask them to notify you about in terms of effects/side effects/possible interactions....
What are some hard rules of medication administration that should never be broken? : r/nur reddit
Other guides
Advice, not law.
- Post-Visit Patient Understanding About Newly Prescribed Medications - PMC pmc.ncbi.nlm.nih.gov
- Medication Administration Errors | PSNet psnet.ahrq.gov
- How to Speak Up About Medications and Side Effects to Protect Your Health pharma-doc.net
- What to Do When a Medication Makes You Worse, Not Better? | Brooks Law Group brookslawgroup.com
- Progress Notes Examples & Templates (2026) | Behave Health behavehealth.com
- How to Talk to Your Psychiatrist About Med Changes psychiatry.top
- Medication Side Effects and When to Get Help silouhealth.com
- Normal Side Effects vs. Wrong Med: How to Tell if Your Psychiatric Medication Is Working — talkingtwenties.com