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PRN Medications - Documentation Requirements

Do all PRN medications need to be documented ?

Any examples are for illustrative purposes only.

Yes, all PRN medications the patient is actively using to treat existing health conditions must be documented. Examples would include Nitroglycerin for chest pain associated with coronary artery disease or ibuprofen for ongoing arthritis pain.

PRN medications the patient may have in the home but are not actively used to treat an existing health condition would not need to be documented. Examples would include pseudoephedrine without recent sinus congestion or acetaminophen without a recent headache. The patient should be informed not to self-administer any medications that have not been reviewed by the physician.
Last updated on March 04, 2021
Manual: Home Care
Chapter: Record of Care Treatment and Services RC

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