Table 2.

Table 2 Documentation (or lack thereof) for 756 Omitted Medication Doses

Omission Category	Reason	Frequency (%)
Unexplained or Unknown	Not charted—reason unknown ∗	282 (37.3)
	Not on administration record for date/time†	31 (4.1)
Partially Explained	Held, reason not documented	80 (10.6)
	Patient post operative/unable to swallow	7 (0.9)
Fully Explained	Held for medical reasons	165 (21.8)
	Patient refused	55 (7.3)
	Ordered and discontinued within 60 minutes	29 (3.8)
	Patient off floor	24 (3.2)
	Patient discharged	24 (3.2)
	Patient taking nothing by mouth	22 (2.9)
	Discontinued prior to shifted schedule	19 (2.5)
	Drug not available on ward	9 (1.2)
	Patient near terminal/care withdrawn	6 (0.8)
	No intravenous access	3 (0.4)
Total		756 (100)

^∗ Not charted—reason unknown coded for orders that were transcribed to the medication administration record but were neither charted as given nor charted as not given.

^† Not on administration record coded for orders that did not appear on medication record (and also not charted). The order may not have been transcribed to the medication administration record.

The reason for the omissions in the Unexplained or Unknown category is unknown.

Omissions in the Partially Explained category were not fully documented. The omission was assumed to be intentional because the dose was circled as held or the chart notes indicated the patient was immediately post operative and not taking oral fluids.

Omissions in the Fully Explained category were fully documented and with appropriate reasons for holding or omitting the dose.