When your patient is sedated and the MAR doesn't explain it

An hour ago the patient was chatting with you. Now you walk in and they're snoring, hard to wake, slurring. Maybe the pupils are pinpoint. You pull up the MAR and find nothing that fits: no PRN opioid, no benzo, no new sleeper. Assess first. Then your note has to show what you saw, what you did and who you told. It doesn't guess at why.

The short version

• Assess and act before you write. Airway and breathing first. Count respirations for a full minute, then get SpO2, pupils, BP, glucose and level of consciousness. Call the provider or rapid response, and follow your protocol or orders for naloxone.
• Chart what you saw, in numbers. Respiratory rate, sedation score, pupil size, what it took to wake the patient. Not just lethargic.
• Write that the MAR shows nothing that explains it. List what you checked: the MAR, the pharmacy dispensing record, patches on the skin, anything at the bedside. Then stop.
• Keep theories out of the chart. Diverted, someone gave him something, family brought pills: all of that goes in an incident report or a call to your supervisor. Not in the progress note.
• Chart every notification by name and time, with the response and the follow-up.

What to write instead

What makes these notes useful:

• Name the stimulus. Voice, loud voice, touch, sternal rub. One word, and the reader knows how deep the sedation was.
• **Put counted x 1 full min next to the respiratory rate.** It shows you counted. The number didn't come off the monitor.
• Say what you ruled out. A glucose, a patch check, a neuro check. Proof you looked past the meds.

Copy this

Progress note / nursing note

``` [DATE] [TIME]: Pt found [POSITION, e.g. supine in bed / slumped in wheelchair]. Level of consciousness: [e.g. eyes closed, did not respond to normal voice; opened eyes to LOUD VOICE / SHOULDER SHAKE / STERNAL RUB; fell back asleep within [NUMBER] seconds]. Sedation score: [SCALE NAME] [SCORE]. Speech: [e.g. slurred / unable to answer / answered name only]. RR [NUMBER]/min counted x 1 full min, [shallow / regular / irregular]. SpO2 [NUMBER]% on [RA / O2 L/min]. BP [NUMBER/NUMBER]. HR [NUMBER]. Temp [NUMBER]. FSBG [NUMBER]. Pupils [SIZE] mm bilat, [brisk / sluggish / nonreactive]. Neuro: [grips equal/unequal, facial symmetry, moves all extremities Y/N]. Baseline per last assessment at [TIME]: [e.g. alert, oriented x3, RR 16].

MAR reviewed: no [opioid / benzodiazepine / sedating medication] documented since [TIME]. [Dispensing cabinet record reviewed: no removals for this pt since TIME / removals listed: WHAT, TIME.] Skin checked for transdermal patches: [findings, e.g. none / one fentanyl patch R upper arm dated DATE per order]. Bedside and personal belongings checked per facility policy: [findings].

[TIME]: [PROVIDER NAME, TITLE] notified by [phone / page / in person]. Reported: [RR, SpO2, LOC, pupils, no MAR explanation]. Orders received: [LIST, e.g. naloxone DOSE ROUTE, labs, monitoring]. [TIME]: [Rapid response called / not indicated per provider]. [TIME]: [INTERVENTION, e.g. naloxone 0.4 mg IV given per order/protocol]. [TIME]: Response: [LOC, RR, SpO2, pupils after intervention]. [TIME]: Charge RN / supervisor [NAME] notified. Plan: reassess [INTERVAL] x [DURATION]. [Continuous pulse ox / other]. [YOUR NAME, CREDENTIALS] ```

Follow-up reassessment entry

`` [DATE] [TIME]: Reassessment. LOC: [e.g. alert, oriented x3 / arousable to voice]. Sedation score: [SCALE] [SCORE]. RR [NUMBER]/min counted x 1 full min. SpO2 [NUMBER]% on [RA / O2]. BP [NUMBER/NUMBER]. HR [NUMBER]. Pupils [SIZE] mm, [reaction]. [Any change since last check.] [Provider updated at TIME / no new orders.] Next reassessment [TIME]. [YOUR NAME, CREDENTIALS] ``

Message to charge nurse / supervisor (separate from the chart)

``` [DATE] [TIME] To: [SUPERVISOR NAME, TITLE] From: [YOUR NAME, CREDENTIALS], [UNIT]

At [TIME] I found [PATIENT/RESIDENT IDENTIFIER, ROOM] with decreased level of consciousness: [brief findings, e.g. RR 7, SpO2 86%, pupils 2 mm, arousable only to sternal rub]. The MAR shows no opioid, benzodiazepine or sedating medication since [TIME]. [Dispensing cabinet record: FINDINGS.] [Provider NAME] was notified at [TIME]. [Intervention and response.] Current status as of [TIME]: [findings].

I have no explanation for the sedation based on documented medications. I am reporting this so it can be reviewed under [facility policy / incident reporting process]. Incident report [submitted at TIME / number NUMBER]. ```

Words that do the damage

If you remember one thing

Four things in the note: a respiratory rate you counted yourself, the stimulus it took to wake the patient, the fact that the MAR doesn't explain it, and who you told and when. Why it happened goes in the incident report. Not the chart.

What goes wrong

The most common mistake is writing a conclusion where the observations should go. You find a resident with a respiratory rate of 6 and tiny pupils, and the note says Pt appears to have received opioids not ordered. Or the opposite: Pt sleeping comfortably.

Both get you in trouble. For different reasons.

• The conclusion replaces the facts. Say the note reads received opioids and has no respiratory rate, no pupil size, no sedation score. Nobody reading it later can tell how sick the patient was or whether your response matched. You saw the real evidence. It just never made it onto the page.
• Normalizing hides the event. Sleeping comfortably is an easy shortcut, especially on nights. But if the patient was actually hard to rouse, the record now says nothing was wrong, and the next shift, the provider and any chart reviewer will believe it.
• Guessing at the cause creates new problems. Hypoglycemia, stroke, sepsis, CO2 retention, a med given but not charted, a missed extra fentanyl patch: plenty of things look like opioid or benzo effect. Write a cause you haven't confirmed and the record is wrong the moment the real one turns up. If you think a controlled substance went missing, send it through your facility's reporting channel. That's where someone can actually look into it.

Same fix every time. What you observed, what you checked, what you did, who you told. With times.

What the guidance says

• Drowsiness and confusion are classic opioid effects. The dangerous one is slowed breathing, so respiratory status is what you assess and document first. (mass.gov, APSF)
• Opioids plus benzodiazepines carry far more risk than either one alone. Look at everything the patient is getting, not just the last dose. (CMS, APSF)
• Pupils are a good clue. Pinpoint points toward opioid effect, so chart size and reaction. (EMCrit, Geeky Medics)
• Score sedation on a standard scale instead of describing it loosely. Use whichever one your facility approved. (Advocate Health, The Anesthesia Guide)

It is not hypothetical

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.

• Texas San Marcos Treatment Center, L.P. D/B/A San Marcos Treatment Center v. Veronica PaytonTexas Court of Appeals, 3rd District (Austin) · 2015-02-10 · full opinion

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 vast majority of off counts I've seen gave an explanation that becomes apparent quickly. I'd just make sure to triple check narc counts in the future. ... Honestly I say this all the time! We have every med under the sun to choose from, but we gotta be extra careful about our Sildenafi

  r/nursing on Reddit: Missing Narcotic- need advice reddit

• I'm not going to wake up someone who has finally managed to get comfortable and needs that sleep for healing. Also when I'm thinking pain medications it's iv pushes, which isn't safe to give to someone who's not awake. One of the parameters you chart on is whether or not thi

  r/nursing on Reddit: How do you handle PRN pain meds? reddit

• Any of those things can make the med pass more dangerous and is something you would need to remember if the BON has any sort of investigation (which I doubt they will, but if they do, it may not be for a few years). Write down the info, the meds that were given, and the patient outcomes. Save those

  r/nursing on Reddit: Medication error cus possibly lose my license. reddit

• I then decided to just tell my charge nurse and she told me to just chart that I didn't scan it, and I then told that to the resident. Another nurse I trust that's been there for 7+ years told me that it's not the biggest deal and then I could've overrode pull another vial and th

  r/nursing on Reddit: Made a narcotic med error 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.

• The Care of Residents with Opioid and Stimulant mass.gov
• Medication Risk Alert: Opioids & Benzodiazepines cms.gov
• FDA requiring Boxed Warning updated to improve safe use ... fda.gov
• Moderate (conscious) Sedation Guidelines for RNs Managing ... oklahoma.gov
• 23.6 Medication Documentation cga.ct.gov
• Opioid intoxication - EMCrit Project emcrit.org
• Respiratory Depression and Opioids - Anesthesia Patient Safety Foundation apsf.org
• Solved: A patient presents after a suspected benzodiazepine overdose. They are drowsy but gauthmath.com