Documenting on Discontinued Medications

Have you ever spent a solid portion of time staring at a patient’s eMAR trying to figure out how to document that you have removed a fentanyl patch because the order was discontinued – or any other medication for that matter??? Did your inability to resolve this issue cause anger, frustration, and just a general feeling like you are stuck in a system you do not understand?

Unfortunately, we are currently unable to document on discontinued meds.

This poses a problem for nursing to identify on the eMAR what was done with a medication once it was discontinued. For now, while this issue gets addressed at a higher level, we ask that nursing document their actions on a discontinued medication in a note, or consult with the physician about re-ordering the medication so that proper documentation can happen.

Write a Note

Select the Medication Note option from the Write Note tab of the patient’s chart.

Then document in that note what action was taken.

If a medication required a co-signature, the nurse performing waste witness should enter a note on the patient’s chart separately, indicating that they witnessed the medication being removed/wasted, etc.