Objective:
The documentation is one of important aspects in the clinical nursing practice. How to articulate the effectiveness of PRN medication and communicate easily between the health care team, the study shows that the PRN Medication Follow Up Report is a very useful assessment tool in the clinical settings.
Methods:
Patients are assessed before PRN medication given and re-evaluated after that. Date, time, medication, reason, ASAS score, and re-evaluation results are documented in this form.
Results:
The form of PRN Medication Follow Up Report was piloted in the Palliative Care Unit with great satisfaction from the health care team. It has been incorporated into the new hospital nursing department documentation system.
