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.

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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 (MM.05.01.07 EP 5).
The inclusion of patient preference into the medication order 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.

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.

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

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: Hospital and Hospital Clinics

Chapter: Medication Management MM

Last reviewed by Standards Interpretation: November 17, 2022