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SOP: PRN Medication Documentation Standards

Standards for documenting PRN medications, including assessment and effectiveness checks.

SOP: PRN Medication Documentation Standards

How to document PRN (as-needed) medications in a way that is safe, compliant, and clear.

Before administration

  • Verify indication and last dose time.
  • Assess symptoms and pain scale.
  • Confirm non-pharmacological attempts when appropriate.

During administration

  • Five Rights check (resident, drug, dose, route, time).
  • Educate resident on purpose and expected effects.

After administration

  • Reassess effectiveness within ordered timeframe (e.g., 30–60 minutes).
  • Document outcome and any side effects in eMAR.

Download: PRN Documentation Quick Card (PDF)

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