Adherence to Orders - PRN Medications

DNV Finding - Medical Record Review (Review orders, flowsheets, and eMAR documentation for the last 2-3 shifts as applicable.)

Which department are you completing this survey for?

Patient MRN?

Do all PRN medication orders have a clear and appropriate indication for use?
What element was noncompliant?
If there are more than one medication with the same indication for use, do the medications identify which medication to administer first?

Ex: 1st choice, 2nd choice
What element was noncompliant?
Is the sequencing logical? Does it clearly identify administration order?
Was element was noncompliant?
Did nursing follow 1st/2nd choice?
What element was noncompliant?

Ex: Tylenol orders as 1st choice, Motrin ordered as 2nd choice, RN gave Motrin prior to Tylenol
Did the RN follow the indication for use as ordered?

Ex: Medication given PRN for Nausea/vomiting. (Validate supporting documentation of n/v in flowsheet)

Ex: Following the range order for pain medication? (Order for mild pain = pain score 1-3) (Order for moderate to severe pain = pain score 4-10) **Confirm supporting documentation in the flowsheet.
What element was noncompliant?
Additional comments/findings