Are there circumstances when a provider may write PRN medication orders that allow variation in administration based on patient preference such as in the following example? "Orders are written to administer 'acetaminophen for mild pain' and 'hydromorphone for moderate pain'. However, due to the side effects of hydromorphone, the patient requests to take the acetaminophen even though pain was reported as 'moderate'.

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Any examples are for illustrative purposes only.

The practice described may be acceptable as long as an organization has determined ALL of the following:

That the medication order is written in a manner that supports deferring to patient preference when:
Requesting a lesser potent medication. (Potency should be established with an evidence based tool i.e. morphine equivalents).
Requesting a lesser prescribed dose in a range order.
Requesting a less intrusive route of administration if both routes are prescribed by the provider.
The medication is administered in accordance with orders from the Licensed Independent Practitioner (MM.06.01.01 EP 3).
The inclusion of patient preference into the medication order cannot subsequently create a therapeutic duplication with other prescribed medications.

The organization's medication management policy (see MM.04.01.01 EP 1) identifies this type of medication order as deemed acceptable, and defines all required elements of such orders.

The use of a protocol is not required. However if an organization chooses to utilize a protocol or standing order, the review and approval process must comply with the requirements found at MM.04.01.01 EP 7. The medical record must contain evidence of an order to implement the protocol as well as the protocol itself.

That implementing such orders or protocols is not outside of the RN scope of practice as defined by state law/regulation,

The medical record must accurately reflect that the lesser potent medication was administered based on patient preference (RC.02.01.01 EP 2). It is NEVER acceptable to administer a medication of stronger potency based on patient preference.

Each organization is responsible for determining how such orders are to be entered into the medical record. The following are example for consideration:

Acetaminophen 325 mg 2 tablets po every 4 hours prn mild pain.
Hydromorphone 2 mg 1 tablet po every 4 hours prn moderate pain. May administer less potent prescribed medication based on patient request per the organization's medication management policy (MM.04.01.01).

The policy must be explicit in that such an order is ONLY for administration of a different (lesser) agent, or a lower dose of the same agent. If the policy allows a lower dose of the same medication, the reduced dose would have to be a part of an existing range order.

Manual: Behavioral Health

Chapter: Medication Management MM

First published date: May 16, 2019