PRN Prescription Medication SDS 0812 4/03



| |

|PRN Prescription Medication |

|(RN Parameters) |

This is not a prescription.

Because a non-nurse care provider cannot give PRN prescription medications without specific written parameters from the physician, registered nurse or pharmacist, please complete the following so that medication administration can occur. Thank you.

|Client: |      |Date: |      |

|Prime #: |      |Case Manager: |      |

|Medication Name: |      | |Generic | |Trade |(Check one) |

|What is the medication for? |      |

|Dose of medication: |      |Amount to be given: |      |

| |(e.g., 4 mg.) | |(e.g,. one tablet) |

|Schedule: |      |Route: |      |

| |(e.g., every 6 hours) | |(e.g., by mouth, under tongue) |

To be given if: (Specific reason medication is needed, e.g., pain in back – not just pain.)

|      |

Not to exceed: (Number of doses in a specific amount of time, e.g., 6 tablets in 24 hours.)

|      |

Call Physician/NP/Pharmacist and/or RN: (Specific adverse reactions, side effects.)

|      |

|To be discontinued: |      |

(When should the medication no longer be given?)

|Physician contacted regarding above information? | |Yes | |No | |Not applicable |

| | |      |

|RN Signature | |Date |

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