PRN medication documentation

[kristimarieSC]

My class has not focused on hand-written documentation because of the decreased need with click and scroll charting. I now have a clinical instructor who values hand written documentation and find myself at a loss. I need to submit an example of in-depth PRN med admin documentation, but am finding resources that cover things like SOAP notes deal more with patient assessment than action. Can anyone help me with either a good example, or a resource that can help me master the skill? I would be super grateful!

[203bravo, MSN, APRN]

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 :)

[Summer Days]

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.