What should be included in a medication progress note?

Including the reason why a medication was not administered in a medication progress note is crucial for maintaining accurate medical records and ensuring continuity of care. This information helps healthcare providers understand the patient's medication regimen, allows for proper assessment of the patient's condition, and facilitates communication among the care team. Documenting the reasons for non-administration can reflect issues such as patient side effects, refusal of the medication, or other clinical considerations, thus informing future treatment decisions.

The time of administration, vital signs, and instructions for the next dose are all important components of a medication record as well, but they typically do not address the specific reasons for not administering a medication, which can be critical in understanding how the patient is responding to their treatment plan. Additionally, ensuring that reasons for non-administration are documented helps prevent misunderstandings about a medication's effectiveness and addresses any potential issues with adherence.