Recording Not Given

How to document a dose of medication as not given in the Drug Chart.

1. From the Drug Chart, click on the dose administration box for the dose you want to record as Not Given.

2. The Recording pane will open. If you are retrospectively documenting a medication that was Not Given earlier, change the Performed date/time to the correct time this was attempted.
3.  Tick the Not Given tick box at the bottom of the window .
4. In the Reason mandatory field, select the appropriate reason from the drop down.

5. If the appropriate reason is not listed, select Other (Record Comments), and click the Comments button.

6. Type a comment and click OK.

7. Sign the documentation using the green tick in the top left hand corner of the window .

8. The dose administration box will now display Complete.

9. Refresh the drug chart. Not Given and the reason will now display in line with the drug name at the time entered.

10. To view comments, right click on Not Given and select View Comments.