Documentation of psychotropic pro re nata medication administration: An evaluation of electronic health records compared with paper charts and verbal reports

Abstract

Efforts to address the quality of documentation, particularly for PRN administration, are needed. This could be made through training, using structured report templates and by switching to electronic databases.

How forensic mental health nurses’ perspectives of their patients can bias healthcare: A qualitative review of nursing documentation

“…According to the College of Nurses of Ontario (2014), documented information is expected to be “clearly, concisely and accurately” reported (p. 9). However, researchers have questioned both the veracity and the thoroughness of nursing notation (e.g., MacAuthur, 2016; Martin, Ham, & Hilton, 2018; Shoqirat, Mahasneh, Dardas, Singh, & Khresheh, 2019). Inadequacies or distortions in notations are problematic as these notes are intended to facilitate communication within multidisciplinary teams and often are the basis of assessments and evaluations conducted by other professionals.…”

PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review

“…Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities.Pharmacy 2019, 7, 157 2 of 14 and organizational routines [11,12]. Decision-making is a key skill for many healthcare professionals and is important to ensure patient safety [13].PRN prescription and administration is commonly used for psychotropic and psycholeptics medications, including antipsychotics, neuroleptics, anxiolytics, sedatives, and hypnotics [6,8,9,[14][15][16][17][18], analgesics [6,12,14,[19][20][21], gastro-intestinal preparations [12,14], and other physical and psychological symptoms [2]. Benefits of PRN administration to patients are noted [2,9], but the use of PRN psychotropic medications has been linked to an increased risk of falls [22][23][24], infection, or dehydration [24].…”

“…While potentially inappropriate use of PRN medications [24] has been reported, one study of PRN medication administration based on medication charts in residential aged care services has shown that rates of administration of PRN medications are lower than anticipated [12]. However, this might have been attributed to a lack of documentation, poor concordance between written notes and verbal reports [16,29], and the use of self-report and phone interviews to assess PRN medication use [30]. Since then, the use of electronic health records in hospitals has increased the accuracy of data collection on the quantity of PRN medication, its prescription, and its administration [16].PRN medicine use in long-term care settings has long been considered integral to medicines management systems.…”

“…However, this might have been attributed to a lack of documentation, poor concordance between written notes and verbal reports [16,29], and the use of self-report and phone interviews to assess PRN medication use [30]. Since then, the use of electronic health records in hospitals has increased the accuracy of data collection on the quantity of PRN medication, its prescription, and its administration [16].PRN medicine use in long-term care settings has long been considered integral to medicines management systems. However, there are few systematic reviews of PRN medicines management in long-term care settings, and those available provide an overall description of PRN only in nursing homes and without a focus on psychotropics medicines [25], the class of medications most commonly administered to residents as PRN.…”

“…However, this might have been attributed to a lack of documentation, poor concordance between written notes and verbal reports [16,29], and the use of self-report and phone interviews to assess PRN medication use [30]. Since then, the use of electronic health records in hospitals has increased the accuracy of data collection on the quantity of PRN medication, its prescription, and its administration [16].…”