PRN medication documentation

Not sure exactly what you are looking for... PRN medications are prescribed for a specific situation and thus the situation that existed that needed the medication administration, the exact time that the med was given, then a follow up note of any changes would need to be documented.

for example: PRN pain meds --- document OPQRST prior to med and then follow up with pain relief afterwards.

PRN breathing treatment -- document breathing effort and lung sounds prior and after administration.

PRN Tylenol for fever -- what was the temp prior and after?

Don't make it more difficult than it needs to be :)

Taking the tylenol example from the above poster, here is an example: "PRN Tylenol 650 mg PO given at 0530 for a throbbing headache, pain level of 5/10. Will reassess intervention in 1 hour."

Side note: go purchase "charting, an incredibly easy pocket guide" by lippincott. Your documentation will never be the same.