Contents
1 Aim
The aim of this document is to set down the standards for prescribing when required medication (PRN).
2 Link to overarching manual
This document links to the overarching safe and secure handling of medicines manual.
3 Definition
PRN (pro re nata) medication is medication that has been identified as being needed to be occasionally administered in particular circumstances on an as and when basis.
4 Prescription
A clear need must be identified for the need of when required (PRN) medication, rather than it might be needed. The review or initiation should be carried out during the patient review. If it is out of hours and a normal team medic is unavailable, then consideration of the once only section of the drug card should be strongly considered.
An unambiguous indication must be stated, for example, for pain, for rapid tranquillisation, if patient refuses regular oral medication:
- clear dosage instructions must be stated
- what dosage, for example, 1mg, one puff
- suggested maximum frequency based on clinical need, ideally in hours, for example maximum every 4 hours
- maximum total dose per 24 hours
- if a dosage range is written it must be clear when to use different doses
The 24 hour period is a rolling 24 hours, not midnight to midnight. The exception to this may include the use of hypnotics which would be administered just prior to retiring to bed, which will vary from day to day.
If there is a need to prescribe the same drug by two different routes, this must be written as two separate prescriptions. Consider using the electronic prescribing medicines administration (EPMA) grouping functionality to link these together.
If two drugs or variable doses are being used for a similar indication, ensure it is clear for the person administering to know when to use them, for example, first or second line.
If the requirement is it is to be used a certain number of times before active review, consider crossing out any additional slots on the administration record. It must be reviewed at least every seven days. When no longer needed the medication should be discontinued to reduce the chances of misadministration.
Take into account any regular medication the patient is taking, this should also be indicated in the total maximum 24 hourly dosage where appropriate.
Guidance should be given if PRN medication may be given just before a regular dose of the medication, for example, Lorazepam.
Where there is either a T2, T3, or S62 in place this must reflect PRN medication as well.
If the use of medication is going to take the total dose of that medication or class of medication above British National Formulary (BNF) limits, then this must only be written or recorded after discussion with the patient’s consultant or their deputy and this must be clearly documented within the patient’s records. If the high dose medication involves antipsychotics the high dose antipsychotics protocol must be implemented, and this must be clearly recorded.
A clear treatment plan should be included in the clinical record, including a maximum period before review. This should include what alternatives should be considered prior to the decision to administer, in order to deliver person centred care, including unintended consequences, such as increased falls risk.
5 Administration
The use of PRN medication must be care planned.
Consider the use of medication and the most appropriate way of dealing with the issue, for example, for agitation has talking or distraction been considered:
- is the prescription clear and unambiguous?
- what regular medication has the patient already received?
- when was the PRN last given, how much have they already been given in the last 24 hours?
- is it in line with any consent to treatment documentation?
Explain the purpose and likely effects of the medication to the patient, and to report any problems to the nurse. Due consideration should be taken of capacity issues, where patients are unable to understand the nature of the PRN medications.
5.1 Recording
The administration must be recorded on the drug chart at the point of administration and then there should be an entry in the record of why it was given and what the outcome was. This may be done one by one basis, for example, the use of Lorazepam for agitation or behavioural control. In these instances, there should be a corresponding entry on the administration record on the medication chart. Alternatively in areas such as the hospice where the prn medication is used as a part of the regular treatment plan a single entry in the tabbed journal covering that shift, where they are discussed daily.
6 Leave or discharge
When a patient is going on leave the PRN medication should be reviewed. If it is decided that it should continue, then the to take out (TTO) should reflect how many doses the pharmacy should issue. In most cases PRN medication will no longer be required, and the inpatient card amended accordingly.
A clear description should be given to the patient on how to use it.
Where appropriate instructions for carers or relatives should be provided, ideally in a written format.
Guidance should be included in the discharge letter on how it should be reviewed, and by whom.
Document control
- Version: 2.
- Unique reference number: 551.
- Approved by: Clinical policy review and approval group.
- Date approved: 7 March 2023.
- Name of originator or author: Medicines management committee.
- Name of responsible individual: Executive medical director.
- Date issued: 26 March 2023.
- Review date: 31 March 2026.
- Target audience: Trust wide.
- Description of change: Full review, page 3 section 5,”this should be recorded as an administration note on the administration chart”.
Page last reviewed: April 24, 2024
Next review due: April 24, 2025