Prescribing PRN medications to manage agitation and psychotic behavior may expose psychiatric inpatients to unnecessary psychotropics or overmedication.1 Moreover, nurses’ documentation of “as needed” administration is often inadequate2 because of the volume of required documentation, nursing shortages in inpatient settings, and nurses’ differing opinions on how to pharmacologically manage difficult behaviors and persistent pain.3
In the absence of evidence-based guidelines,4 the following recommendations can help you ensure that PRNs are used safely and documented thoroughly.
Document the rationale for ordering a PRN in your progress notes. Note the behaviors you wish to target, and specify when nurses should administer the drug.
Review nursing progress notes to determine whether the drug rectified the targeted behavior(s). For partial response, consider increasing the dosage. For nonresponse after 2 doses of one agent, try switching to another.
Review medication administration sheets to determine how often a drug is being used. Frequent PRN use suggests a need to re-evaluate the patient and drug regimen. You may need to increase or add to the patient’s standing medications. Consider combining similar medications into a standing order for more-reliable administration.
Request staff education. One study suggests that PRN orders can benefit staff more than patients.1 Advocating for the education of direct-care staff may be psychiatrists’ most effective method of combating PRN medication overuse.
Improper charting or misestimation of PRN use could result in liability. For example, medication that is not immediately documented may be re-administered by another nurse, resulting in overdose. A physician’s clinical judgment is impaired if he or she relies on inaccurate documentation or verbal report when evaluating a patient’s PRN use and standing order.
Education, auditing of records, and corrective action can help maintain charting accuracy and reduce the risk of litigation.3