A nurse incorrectly gave 2 mg of lorazepam (Ativan) to a patient instead of the 1 mg ordered PRN for anxiety. Which of the following demonstrates appropriate documentation of this in the patient's medical record?

2 mg lorazepam PO given at 1300. Physician informed, no further orders. Vital signs were WNL 30 minutes and 1 hour later. Patient watched TV in day area until dinner.

Explanation

•This is the correct documentation: 2 mg lorazepam PO given at 1300. Physician informed, no further orders. Vital signs WNL at 30 min and 1 hr. Patient watched TV in day area until dinner.

•Documentation of med errors should be factual without stating that an error was made. The time of the event as well as the details such as the drug, dose, and any effects observed should be noted. Always document what you did (calling the physician) and any new orders if there are any. Objective assessments pertaining to the effects or lack of observable effect can be added.

Incorrect options:

•This is incorrect: Lorazepam 2 mg given at 1300 hrs instead of 1 mg per order.

•This option is factual but does not provide enough information: 2 mg lorazepam given. Patient appears fine. (What time was this drug given? Was the doctor called? What are the objective signs that the patient is "fine?").

•This option is wrong because it explicitly states that an error was made:  Med error. Lorazepam 2 mg given at 1300 hrs instead of 1 mg per order. No adverse effects noted. Remember: Never document in a patient's chart that an error was made.

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