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Medication Administration - Incorporating Patient Preference Into Medication Administration Practices

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 examples ? Example 1: 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'. Example 2: A post-partum patient has PRN pain medications written as follows: morphine for severe pain, hydromorphone written for moderate pain and acetaminophen written for mild pain. New moms who report moderate or severe pain may request to take the acetaminophen as they do not want to take the other medications as they are breastfeeding.

Any examples are for illustrative purposes only.

The practice described may be acceptable as long as an organization has determined that:
  • The medication order is written in a manner that supports deferring to patient preference when the patient is:
  • 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 following also apply:
  • The medication is administered in accordance with orders from the Licensed Practitioner. 
  • The inclusion allowing patient preference is in the medication order and does not subsequently create a therapeutic duplication with other prescribed medications.
  • The organization's medication management policy identifies this type of medication order as 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, the review and approval process must comply with the requirements found at MM.04.01.01 EP 15.  The medical record must contain evidence of an order to implement the protocol, as well as the protocol itself.
  • Implementing such orders or protocols is not outside of the RN scope of practice as defined by state law/regulation.
Therefore, there must be a policy which allows such, the order must include verbiage of such and the medical record must indicate that the patient preferred the less potent agents.  This does not allow a patient to request a dose not prescribed in a written medication order.

Per the requirements of the Record of Care, Treatment, and Services (RC) chapter, the medical record must accurately reflect that the lesser potent medication was administered based on patient preference. It is NEVER acceptable to administer a medication of stronger potency based on patient preference.
The policy must be explicit in that such an order is ONLY for administration of a different (lesser) prescribed medication, or a lower prescribed dose of the same medication.  

Manual: Critical Access Hospital
Chapter: Medication Management MM
Last reviewed by Standards Interpretation: September 05, 2023 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: March 13, 2017 This Standards FAQ was first published on this date.
This page was last updated on January 30, 2024 with update notes of: Editorial changes only Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
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