Northstar of nebraska

Guidelines for Use of Med 27 PRN Med Log
The purpose of these guidelines is to provide directives for the use of the Med 27 PRN Med Log, which records the administration of and the response to all prescribed PRN medications by a Medication Aide. Prescribed PRN (as needed) medication will be defined as: a. PRN non-routine prescription or OTC medication
Example: “milk of magnesia 30 cc PRN if no BM in 4 days” or “Albuterol 2 puffs PRN every 4 hours for wheezing” b. PRN short-term routine prescription or OTC medication
Example: “Lotrimin Ointment BID x 5 days PRN rash” or “Zyrtec 10 mg daily x 10 days PRN allergies” NOTE: Psychotherapeutic medication cannot be given PRN
The Med 27 PRN Med Log will only be used for the following:
a. PRN non-routine prescription or OTC medication NOTE: this does not include medication listed on the Med 5 -
Approved PRN OTC Medication form which would be documented on the Med 6 – PRN OTC Med Log b. PRN short-term, routine and non-routine doses of ALL pain
NOTE: all other PRN short-term routine prescription or OTC
medication will be documented on the Med 1 - Medication Administration Record Each prescribed PRN medication must have a specific order from a Healthcare Professional Each prescribed PRN medication will have written directions from the Agency Nurse, utilizing one of the following: b. RN 4 – Person-Specific Med Protocol The Agency Nurse will determine and provide any additional training The form will be used to document the administration of the medication, the response to the medication and the inventory of the medication A Medication Aide or Medication Recorder will complete the following: a. Rows 1 – 4 in the “Order” section on page one b. Rows 1 - 2 in the “Order” section on page two c. Record their initials and the date in row 5 on page one d. Record their signature, position and initials at the bottom of page The form will be reviewed for accuracy by a Medication Aide or Medication Recorder and the following will be recorded: a. Their initials and date in row 5 on page one b. Their signature, position and initials at the bottom of page one The form will be kept in the Individual Medication Book Each time the PRN medication is administered, the Medication Aide will record the following: The Medication Aide who observes the response to the PRN medication will complete each of the following sections: Counts (daily, double, weekly and monthly) and movement of medication in and out will be recorded on page two, according to “Count” procedures Any PRN medication listed on a Med 27 will be readily available for administration , unless otherwise specified by the Healthcare Professional or Agency Nurse Name: The full name of the individual
Address: the address where the PRN medication is to be administered
Prescriber: the Healthcare Professional that has currently ordered the
PRN medication, this may be the same as the Personal Physician; (if the
Healthcare Professional is supervised by a physician, the name of the
supervising physician will also be listed)
Med - Order: the name of the PRN medication the Healthcare
Professional ordered; this should be copied from the order
Med - Label: the name of the PRN medication EXACTLY as listed on
the pharmacy prescription label
Allergies: the individual's allergies to medication, foods, and other
substances (i.e., bee stings, penicillin, eggs, Tide, etc.); if there are no
allergies, list "none known" or “NKA” (No Known Allergies)
Dosage: the dosage of the PRN medication EXACTLY as listed on the
order
NOTE: If no dosage is stated on the order, record “NA”
RX (Prescription) Number: the prescription number that appears on
the pharmacy label; if the number changes, the new number should be
added to this section
NOTE: If the medication is a routine non-prescription medication that
does not have a pharmacy label, record “OTC” (Over-the-Counter) If samples of medication are given by the Healthcare Professional, record “sample” Purpose: the reason(s) the individual is receiving this PRN medication
Frequency: the frequency EXACTLY as listed on the order
Stop Date: the stop order date
Special Instructions: specific information required for proper and safe
administration of the PRN medication (e.g., drink a full glass of water;
take 30 minutes before a meal; avoid dairy products at administration
time)
Transcriber’s Initials/Date: the initials of the Medication Aide or
Medication Recorder who transcribed the Order section and the date the
Med 27 was transcribed
Reviewer’s Initials/Date: the initials of the Medication Aide or
Medication Recorder who reviewed the Order section and the date the
Med 27 was reviewed
This review must occur to verify that the order section is transcribed correctly Date: month, day & year the PRN medication was administered
Time: the time the PRN medication was administered, including “a.m.”
or “p.m.”
Description of Symptoms: list objectively what you see, hear, touch or
measure, such as:
the discomfort/condition reported by the individual, e.g., individual complained of feet burning, or individual stated "my arm hurts in my cast" the specific observation(s) of symptoms e.g., red, swollen feet with rash, crying and holding casted arm Amt (Amount) Given: the amount of the PRN medication that was
administered
Initials: the initials of the Medication Aide who administered the PRN
medication
Date: the month, day and year the response to the PRN medication is
recorded
Time: the time the response to the PRN medication is recorded,
including “a.m.” or “p.m.”
Response Within 2 hours: any observed changes or responses in the
symptoms, for which the PRN medication was given; record objectively
any comments even when no change or response is observed
Initials: the initials of the Medication Aide who observed and/or
recorded the change or response to the PRN medication
Signature/Position/Initials: the signature, position and initials of any
Medication Aide making an entry
Order section: same as page one
DAILY – DOUBLE – WEEKLY - MONTHLY COUNTS Date: the month, day and year the entry was made
Time: the time the PRN medication was counted, including “a.m.” or
“p.m.”
Balance: the exact amount of PRN medication
Initials: the initials of the Medication Aide or Medication Recorder
counting the PRN medication
Only one action will be made per line (either sign in or sign out the medication) Date: the month, day and year the entry was made
Time: the time the PRN medication was counted, including “a.m.” or
“p.m.”
Beginning Balance: the exact amount of PRN medication prior to
receiving or sending any medication out; if there is no PRN medication,
record “0”
Amount In: the exact amount of PRN medication received ; if no PRN
medication is received, record “0”
Amount Out: the exact amount of PRN medication being sent out; if no
PRN medication is being sent out, record “0”
Ending Balance: the exact amount of PRN medication, after adding the
amount received, or subtracting the amount sent out; if there is no PRN
medication, the amount will be “0”
Initials: the initials of the Medication Aide or Medication Recorder
recording the entry
Comments: record pertinent information regarding the medication, such
as where the medication was received from or sent to and discrepancies
with the amount
EXAMPLES: “Received from pharmacy”
“Sent with parents”
“Pharmacy sent cassette with no spares” Signature/Position/Initials: the signature, position and initials of any
Medication Aide or Medication Recorder making any entry

Source: http://www.northstarservices.net/sites/default/files/Guidelines%20Med%2027.pdf