shift is wild

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When a coworker says she gave it but it's not charted

Your coworker says she gave the dose. The eMAR says it's still due. How to chart the gap without signing for it yourself.

8 min read built on 6 full opinions updated 2026-09-24

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

It's mid-shift. A coworker tells you, Oh, I gave his 0900 metoprolol, I just didn't chart it. The eMAR still shows the dose as due. Now the gap is in front of you, and your job has two parts: keep the patient safe, and write down only what you actually know.

The short version

  • Don't chart her dose as given. You didn't see it, so it doesn't go in your note as a fact. She documents her own dose, usually as a late entry.
  • Record what she said, with her name. In your note it's a report from a named colleague at a specific time. It's not an event you saw.
  • Check it yourself. Look at the eMAR, the dispensing cabinet record (Pyxis, Omnicell) and the patient. Write down what each one showed.
  • Tell someone. Usually the charge nurse. Also the prescriber if you're deciding whether to give or hold a dose. Chart who you told and what they said.
  • Don't repeat the dose or skip it until you've checked. Give it, hold it or clarify it based on a real decision, and chart that decision.

What goes wrong

The usual mistake is a kind one. You want to help, so you write 0900 metoprolol given by Jen, or you just document the dose on the eMAR yourself. Now your signature says something happened that you never saw.

That causes three problems:

  • Anyone reading the chart later takes it as fact. Nothing in metoprolol given says it was secondhand. If the dose was never given, or was given twice, your entry is the wrong one.
  • The records stop matching. Cabinet data, the eMAR and your note get checked against each other. Cabinet shows no pull, your note says given: that mismatch has your name on it.
  • Her gap stays open. You filled it in, so she never writes her own entry. The one person who actually knows is missing from the chart.

The opposite mistake is doing nothing. If nobody writes anything, the chart reads as though the dose was never given. The next nurse might give it again.

It is not hypothetical

Demastus v. University Health System, Inc., Court of Appeals of Tennessee, 2017. Link A compliance officer compared Omnicell pulls against patient charts. She found medications removed with no record that they were given or wasted. When asked, the nurse gave only a verbal account: if she pulled a medication, she either gave it or returned it. She was terminated. The appeals court upheld summary judgment for the employer. The trial court said she had explained the discrepancies by "basically admitting that the records are what the records are." Her word alone didn't close the gap in the chart.

Royal ex rel. Mott v. Blanch, Louisiana Court of Appeal, 2017. Link An ER physician testified that he checked a patient's pulse oximetry at triage and never charted it. It wasn't charted, so the medical review panel concluded the test wasn't done. At trial, a physician who had sat on that panel explained not charted, not done like this: if something isn't recorded, "people are going to assume that you didn’t do it." The judgment for the hospital was affirmed. It still took years of litigation and testimony over something one line in the chart would have settled.

Bishop v. Ohio State Univ. Wexner Med. Ctr., Ohio Court of Claims, 2020. Link A nurse testified that she offered a high-fall-risk patient a bed exit alarm and the patient refused. She never documented the refusal. She admitted she "should have documented plaintiff’s refusal of the bed exit alarm in plaintiff’s chart." The responding physician's note is worth copying. When paged, she first wrote down what she was told. Then she skipped a line, and below it wrote what she found herself at the bedside.

Primes v. State Bd. of Pract. Nurse Examin., Louisiana Court of Appeal, 2008. Link One of the employer's allegations against an LPN was that "No medications were removed from the pyxis machine, and the medications were not charted." The court found no hearing evidence on that allegation and affirmed the trial court's decision to set aside the Board's suspension. The case still shows how cabinet data and the chart get read together.

What to write instead

How it often gets charted How to chart it
0900 metoprolol 25 mg PO given by J. Smith RN.1115 J. Smith RN verbally reported at nurses' station that she administered metoprolol 25 mg PO at approx 0900 and had not documented it. Not witnessed by this RN. eMAR shows 0900 dose not documented. Omnicell shows metoprolol 25 mg removed for this pt at 0852 by J. Smith. J. Smith states she will complete late entry.
Morning meds given per day shift.Per verbal report from off-going RN K. Lee at 1910, all 1700 meds administered. eMAR reviewed: 1700 insulin lispro not documented. K. Lee contacted at 1920, states dose given at 1705; she will enter late documentation. BG 1930: 142. Charge RN M. Diaz notified 1925.
Dressing changed this AM.Day shift RN T. Ruiz stated in handoff at 1900 that she changed L heel dressing this AM; no documentation found in flowsheet. On assessment at 1945: dressing dated [date] with initials TR, clean/dry/intact. Asked T. Ruiz to document her dressing change.
Pain med was given earlier, pt comfortable.2230 A. Park RN stated she gave oxycodone 5 mg PO approx 2000; not on eMAR. Omnicell: no oxycodone removed for this pt since 1600. Unable to confirm dose given. Dr. Nguyen paged 2240, notified of discrepancy. Order received 2250 to give oxycodone 5 mg now. Given 2255. Pain 7/10 before; will reassess at 2355. Charge RN notified.
Discussed with coworker, dose taken care of.Held 1400 dose of vancomycin pending clarification: RN B. Owens stated she hung vanc at approx 1200, not documented, no bag in room, pump history shows no infusion since 0600. Pharmacy and Dr. Hale notified 1410. Awaiting orders.

Every entry in the right-hand column covers the same four things:

  • Who said it, when, and that you didn't see it. Write not witnessed by this RN. Plain words.
  • What you checked and what you found. The eMAR, the cabinet record, pump history, the dressing label, the patient.
  • Who you told, and what happened next.
  • Whether the dose was given, held or clarified, and why.

Words that do the damage

Word or phrase Why it hurts Use instead
given (for a dose you didn't see)Reads as a fact you witnessed[Name] reported she administered…
per day shift / per reportDoesn't say who, when or what exactlyName, credential, time, exact content
confirmedSuggests you checked it yourselfstated, reported (save verified for things you actually looked at, like the eMAR or cabinet)
taken care of / doneSays nothing about what happenedThe specific action: given, held, clarified, late entry pending
apparently / supposedlySounds sarcastic, editorialNot witnessed by this RN.
forgot to chart / didn't bother to chartBlames her or guesses at motiveNo documentation found in [eMAR/flowsheet].

What the guidance says

  • If you chart something you didn't observe yourself, say who it came from. Same for a task another staff member did: name the person who did it. (Maryville Nursing, allnurses)
  • When the chart is silent about a task, readers assume it wasn't done. Good care that never got written down can look like neglect later. (Empowered Nurses, MedLeague)
  • Don't chart for someone else just because she asks. Unless you saw it, the entry belongs to the nurse who did the work. (allnurses, ASRN)

Copy this

Nursing note: coworker reports a dose she didn't document

``` [TIME] [COWORKER NAME, CREDENTIAL] verbally reported to this RN that she administered [MEDICATION, DOSE, ROUTE] at approximately [TIME GIVEN] and had not documented it. Administration not witnessed by this RN.

Verification:

  • eMAR: [TIME] dose [not documented / documented as ___].
  • [Pyxis/Omnicell] record: [MEDICATION] [removed at TIME by NAME / no removal found for this patient since TIME].
  • Patient assessment at [TIME]: [RELEVANT FINDINGS, e.g., HR, BP, BG, pain score, sedation level, IV site/pump history].

Notified [CHARGE RN NAME] at [TIME]. [PRESCRIBER NAME] notified at [TIME] of the discrepancy; orders: [ORDERS RECEIVED / none, continue scheduled dosing].

Plan: [DOSE GIVEN AT TIME per order / DOSE HELD pending clarification / next scheduled dose due at TIME]. [COWORKER NAME] states she will complete a late entry for her administration. Will reassess at [TIME]. [YOUR NAME, CREDENTIAL] ```

Nursing note: coworker reports a task she didn't document (dressing, assessment, line care)

``` [TIME] [COWORKER NAME, CREDENTIAL] stated during [handoff / conversation at TIME] that she performed [TASK] at approximately [TIME]. No documentation of this found in [flowsheet / eMAR / LDA record] at [TIME]. Not witnessed by this RN.

On assessment at [TIME]: [WHAT YOU SAW, e.g., dressing dated ___ with initials ___, clean/dry/intact; IV site ___; patient states ___].

Asked [COWORKER NAME] to document her [TASK]. [CHARGE RN NAME] made aware at [TIME]. [YOUR NAME, CREDENTIAL] ```

Message to the charge nurse (secure chat or in person, then note the time)

`` [CHARGE RN NAME]: FYI on [ROOM/PATIENT INITIALS]. At [TIME], [COWORKER NAME] told me she gave [MEDICATION, DOSE] at about [TIME] but it is not on the eMAR. [Cabinet shows removal at TIME / Cabinet shows no removal.] Patient currently [BRIEF STATUS]. I have [notified PRESCRIBER NAME / not yet notified the prescriber]. I have not charted the dose as given. She says she will do a late entry. Plan for this dose: [GIVE / HOLD / AWAITING ORDERS]. [YOUR NAME], [TIME]. ``

Occurrence / safety report (only if your facility's policy calls for one)

``` Date/time discovered: [DATE], [TIME] Unit/room: [UNIT], [ROOM] Reported by: [YOUR NAME, CREDENTIAL]

Description: At [TIME], [COWORKER NAME, CREDENTIAL] verbally reported administering [MEDICATION, DOSE, ROUTE] at approximately [TIME]. The dose was not documented on the eMAR at time of discovery. [Dispensing cabinet record showed ___.] Administration was not witnessed by the reporter.

Actions taken: Patient assessed at [TIME]: [FINDINGS]. [CHARGE RN NAME] notified at [TIME]. [PRESCRIBER NAME] notified at [TIME]; orders: [ORDERS]. Dose [given at TIME per order / held / next scheduled dose due at TIME]. [COWORKER NAME] informed of need for late entry at [TIME].

Patient outcome at time of report: [STATUS]. ```

If you remember one thing

Chart what she told you, what you checked and what you did next, with names and times. Never chart her dose as if you watched her give it.

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.

  • The only thing I would do is verify the med was not given, then assess the patient to make sure it is appropriate to give the med and document the time I gave it along with a note saying why I had to give it and the steps I took to verify i was corrert in administering the med...

    r/nursing on Reddit: Nurse did not give scheduled meds during her shift, wanted me to docu reddit

  • That's Nursing 101. People who are telling you that it's ok not to document something you did are giving you incorrect information. If you did an assessment because you were supposed to do an assessment, you need to document it. I would go clock in and chart a late entry. Legally speaking,

    r/nursing on Reddit: Forgot to chart an assessment…what do I do? reddit

  • Generally we know enough about each others patients that we can read the chart and fill in the blanks. It bit me in the ass for the first time tonight. Sent a patient up to the floor for my colleague. While giving report, it appears IV ABx weren’t given. I tell nurse I’ll start them before she comes

    r/nursing on Reddit: Do you give/take report for another nurse? reddit

  • Those are easy to forget and easy to back time and chart later. -cluster care, if you’re already going into the room for a call light do a quick assessment (even a pain scale to assess the medication you just gave), make sure your monitor is cycling the BP, look at your vs and rhythm.

    r/nursing on Reddit: Need ED Documenting tips reddit

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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