What must be documented when administering psychotropic medication on a PRN basis?

When administering psychotropic medication on a PRN (as needed) basis, it is crucial to document an evaluation of the resident's symptoms before the medication is given. This documentation serves to ensure that there is a clear understanding of the resident's current state and the specific reason for the medication administration. It helps to establish a baseline of the resident's condition, which is essential for assessing the medication's effectiveness afterward and for making informed decisions regarding ongoing treatment.

Properly documenting this evaluation provides a rationale for the PRN medication use, which is critical for regulatory compliance and continuity of care. It ensures that care providers have access to relevant information about the resident's symptoms, enabling them to monitor the response to the medication and make adjustments as necessary. This practice also enhances the safety of medication administration, minimizing the risk of inappropriate or unnecessary drug use.

In addition to assessing symptoms, it is also important for caregivers to document the resident's mood after the medication has been administered and other related factors for a comprehensive review. However, the key focus before administration is on the symptoms that justify the use of the medication.