how do you chart your prn narcs

CathyLew · Feb 28, 2011

you need to check your policy for your particular hospital. I know the QA dept where I used to work hated having to track down our PRN charting --some was on the MAR some in the note.

turnforthenurse, MSN, NP · Feb 28, 2011

depends on your institution...

I precepted on a cardiac surgery/VICU stepdown unit and all stepdowns/critical care/telemetry units use a trifold sheet to document (which includes a nurses notes page) - as opposed to the med-surg units. they just have your standard chart with tabs, etc. On the units that utilize the trifold, there is also a page for "STAT/PRN medications" - you document them there as well as on the EMAR. On the med-surg units to my knowledge those PRN medications are only documented on the EMAR, not in the nurses notes.

CT Pixie, BSN, RN · Feb 28, 2011

We are a computerized facitlity. When you "sign off" any PRN med another box comes up, and there is where we document the reason for giving. Our facility wants us to also chart in the nurses notes on the effect of the PRN. Once we sign off a PRN there is no way to go back into it to chart the effects of the med, hense we have to chart it in the nurses notes.

Like the others suggested, I'd take a look at your Policys and Procedures to get a definitive answer. DON's are not the end all be all, the P&P is. Corporate won't give a rats back end if i say "I never charted in the nurses notes about the effects because the DON never said I should be doing that"

tewdles, RN · Feb 28, 2011

As others have said, follow the protocol for your facility. Having said that, you should not have to chart it in 2 places. Given that the MAR represents you medication POC, that is where it should be, IMHO.

ackiepieRN · Feb 28, 2011

Like all have said before, its all about the policies and procedures manual. Consider it a second bible. :nurse:

Our documentation of narcotics is ... archaic and annoying to say the least. We chart on the computer what time the medication was given. In the nursing assessment flow sheet there is a box specific for charting PRN narcotics. It is subdivided into further boxes: time, your initials, pain score and location, medication administered (including the amount and route), time of hour re-assessment, re-assessment pain score, your initials again, and circling a Yes/No if the medication was effective. If the medication was NOT effective then we are required to write a nurses note.

SHEESH! :uhoh3:

stacygayle · Feb 28, 2011

The first thing I every learned in the healthcare field is CYA/B"Cover your own Butt". Every state has it's own way but it always good to chart on MAR and in the nurse's notes because if anything comes up you have documentation that clarifies MAR entries.

CoffeeRTC, BSN, RN · Feb 28, 2011

In LTC they are really starting to crack down and look at the presence or frequency of pain. Sooo...what are we doing for it. They want to see if the med is effective and what the pre and post prn pain is being rated.

We've included a spot on the MAR for routine meds to chart Pre and Post med pain levels by a 0-10 number. We also have a sheet attached to the MAR for PRNS. This sheet sent by the Pharm with the MAR print out.

This way..it is documented in one place and you don't need to be charting it in a hundred different places. It is also ease to evaluate the effectivness.

In LTC, esp ours with a good number of rehab pts...I'd be charting for ever and a day if I made a big nurses note everytime I gave a prn in addition to the other notes we have to do.

Forever Sunshine, ASN, RN · Feb 28, 2011

Documenting pain meds has become a focus in my facility too. We've been through about 3 or 4 policies.

We document on the back of the MAR. I usually put a shortened version in my nurses note if I have to chart on that resident. "Resident c/o pain 4/10 in R knee. Percocet given with positive effect."

indigonurse · Feb 28, 2011

This is my take on it the regs, laws, nurse practice act. policy etc. do require that we chart certain things at a certain time, etc. I would look at your facilities policy Manuel and ask the consulting pharmacist where are all the places you are expected to document a prn med. I defiantly would after I gave it and then go back and doc. the effectiveness like you said. But, if the person was on daily charting, had a weekly summary due, I would probably have to mention it again if not then I probably wouldn't.

systoly · Feb 28, 2011

In the absence of facility policy and knowledge of your state regs, I'd be mostly concerned with inconsistencies. Why not ask the other nurses to show you an example of where they have done this and look at their charting. You can also ask them why they feel this is necessary, perhaps the lack of facility policy needs to be addressed.

birthrevolution · Mar 1, 2011

We have to chart in the (paper) MAR and in the actual (electronic) chart in the pain assessment. It's double charting, but they will probably do it this way until we switch to electronic MARs

Oh, I just noticed this was LTC nursing, I'm in acute care, but it came up on the home page, just wanted to clarify.