how do you chart your prn narcs

[mozella]

I always chart in the MAR when I give it and then again in the MAR for the effect. I don't always have time to chart in the nurses notes about it. Is this a requirement as far as state is concerned. My DON has never said anything to me about me not doing it, but other nurses say that I should be. I really don't see in the nurses notes where any other nurses are doing it. Just wondering If it HAS to be in the nurses notes.

[CapeCodMermaid, RN]

Each piece of nursing documentation should be able to stand alone.

In my facility, we chart on the MAR. "Pain 8/10. Two Percocet given" 60 minutes later resident states pain is 2/10.

I wouldn't write a note on just that unless the pain was new or not relieved by the pain med and I had to call the doc for a new order.

[marthyellen]

Each piece of nursing documentation should be able to stand alone.

In my facility, we chart on the MAR. "Pain 8/10. Two Percocet given" 60 minutes later resident states pain is 2/10.

I wouldn't write a note on just that unless the pain was new or not relieved by the pain med and I had to call the doc for a new order.

I agree. An adequate note on the MAR should be sufficient. Every time you document in two places you set yourself up to make a mistake. As long as you go back and do follow up documentation on the MAR.

In LTC, the medication nurse does not have the time to document in two places and she has the MAR at her fingertips.

[rainbowsandsunshine]

We document on the Mar & Narc sheet & Pain Management flow sheet when given, reassess and document the effectiveness on the MAR & Pain management sheet. It is a lot of charting and a big PITA, so if I give PRN pain meds frequently (at least 1-2x EVERY shift), then I ask the MD to reevaluate their current medications and possible include some more scheduled pain meds for chronic pain (I am in LTC)

[CapeCodMermaid, RN]

Regardless of the need to document it is an excellent idea to ask the doc to schedule pain medication if the patient is taking a lot of PRN meds. At one place I worked we had all the docs with ortho patients to order pain meds every 4 to 6 hours around the clock for the first 24 hours and then switch to PRN. We had much better outcomes.