What is the best action when a patient refuses a midnight antibiotic and asserts they have already taken their pills?

• A. Check with previous documentation to confirm timing
• B. Administer anyway
• C. Ignore refusal and document
• D. Call the physician to obtain a new order

Answer: (A)

When a patient refuses a medication, the first step is to verify the dosing history before taking any action. Checking previous documentation to confirm the exact timing of the midnight antibiotic ensures you don’t duplicate a dose or give medication against the patient’s stated choice. Review the MAR and nursing notes to see whether the dose was already administered or whether it’s pending. If the record shows the drug was given, you should not administer it again and you would document the decision. If the documentation is unclear, follow your facility’s next steps, which may involve clarifying with the clinician, but the critical action is to verify with the chart first. Administering despite refusal or ignoring the patient’s input would not align with safe, patient-centered care, and calling for a new order is unnecessary when the record provides clear guidance.