Medication Administration Documentation for Nurses
Medication documentation is among the most tightly regulated parts of nursing. In most settings it happens in an electronic MAR with barcode scanning, but the principles are the same everywhere.
Clinical review status: awaiting review by a licensed nurse reviewer. Last updated 2026-11-10. Read our editorial policy.
The rights of medication administration
Nursing education commonly teaches the five rights: right patient, right drug, right dose, right route and right time. Many programs add right documentation, right reason, right response and the patient's right to refuse.
Document immediately after giving
Record the administration after you give it, never before. If a dose is held or refused, document that with the reason, any education given and who you notified, according to policy.
PRN medications
Document the indication for each PRN dose and reassess its effect within the timeframe your policy sets. A PRN entry without a reason or reassessment leaves the next nurse guessing.
Reconciliation
At admission, transfer and discharge, the home medication list is compared with current orders. Nurses often gather the list; discrepancies go to the prescriber to resolve.
About our medication templates
Our medication templates are for learning and simulation. They contain no orders or doses and must not be used in place of an authorised administration system.