(D) Standard Indications Included (Refer to Appendix A for list of medications)
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1 Name of Policy:PolicyNumber: PRN Indications }-.+-`-+,tr---fi::-'..1- :-` -.,-_ -` E-..,',,=.:~1,EffectiveDate:9/1/2018 Department: ApprovlnResponslScope: g Officer:bleAgent: Pharmacy Chief Executive OfficerDirectorofPharmacyChairofPharmacyandTherapeutics CommitteeUniversity of Toledo Medical Center Initial effective date 10/1/2014 New policy proposal x Minor/technical revision of existing policy Major revision of existing policy Reaffirmation of existing policy (A) Policy statement Physician orders for as needed medications (PRN) will contain all the required elements including indication for use. When an indication is not indicated by the prescriber the FDA approved indication approved by the pharmacy and therapeutics committee will be the defined indication for use. (8) Purposeofpolicy In accordance with The Joint Commission, all medications must have an indication for PRN use. This policy will decrease confusion amongst the nursing staff as to the intent of a medication. (C) Procedure 1. Order for a PRN medication is entered by the medical team. The prescriber may indicate any appropriate indication outside of this policy in the written or electronic order. 2. If no indication is provided the pharmacist and the pharmacy informatics system will assign the approved indication for specific medications. 3. Nursing and medical staff will be notified electronically in the EMR of the approved indication. (D) Standard Indications Included (Refer to Appendix A for list of medications) Allergic Rhinitis Cough 8. Diarrhea 9. DizzinessIvertigo 10. Dry Eyes 1 1. Edema 12. Flatulence 13. Fluid Replacement 14. Headache 15. Hemorrhoids 16. Hiccups Hypotension 19. Indigestion Itchy Skin 22. Migraine
2 23. Muscle spasm 26. Oral Mucositis 24. Nasal Dryness Nausea/ 28. Secretions Urinary /Spasm Approved by: Review/Revision Date:4/1/20179/1/2018 Z _ T8/3 o/ /R Russell smith phalmb BCPS' \ Date `' - Director of Pharmacy c7( ) \q DrHeathe lepaczm Dale I Chairp rmacyan erapeutics committee tr='. Sct~ 3hTei: le::c::ie o,fecset, MB A Z3Z3AcfuTljDt@ i Review/Revision completed By.. Pharmaey Policies Superseded by This Policy: NextReview Date: 9/1/2021 It is the responsibility Of the reader to verify with the responsible agent that this is the most current version of the policy. Appendix A Medication Name class Indication Acetaminophen with Codeine Acetaminophen/Caffeine/Butalbital Albuterol A[buterol and lpratropium Alum-Mag Hydroxide-Simeth Amitriptyline Aripiprazole Aspirin/Caffeine/Butalbital Atenolol Azelastine Belladona Alkaloids-Opium Benzocaine Benzocaine-Menthol Benzonatate Bisacodyl / Barbiturate Beta Agonist Beta Agonist/Anticholinergic Antacid Antidepressant Barbiturate Headache Indigestion Headache Allergic rhinitis Urinary pain or Spasm
3 Bumetanide Buprenorphine Butorphanol Calamine-Zinc Oxide Carvedilol Celecoxib Cetirizine Chlordiazepoxide Chlorpheniramine-Hydrocodone Chlorpromazine Clonidine Codeine Cyclobenzaprine Cyproheptadine Dextromethorphan-GG Dextrose 50% Diphenhydramine Diphenoxylate-Atropine Docusate Epinephrine Eszopiclone Felodipine Fentanyl Fexofenadine Fexofenadine-Pseudoephedrine Fluticasone Furosemide Glycerin Glycopyrrolate Guaifenesin Haloperidol Lactate Hydrochlorothiazide Hydralazine Hydrocortisone (rectal) Hydrocodone/Acetaminophen Hydromorphone lbuprofen lbuprofen-hydrocodone lpratropium Ketorolac Tromethamine Labetalol Lidocaine-Prilocaine Loop Diuretic Topical Skin Protectant Beta Blocker Benzodiazepine Antipsychotic Alpha Agonist Intravenous Nutritional Therapy Antidiarrheal Stool Softener Alpha/Beta Agonist Calcium Channel Blocker /Decongestant Nasal Steroid Loop Diuretic Laxative, Osmotic Anticholinergic Expectorant Typical Antipsychotic Thiazide Diuretic Vasodilator Corticosteroids / Anticholinergic Edema Itchy Skin Anxiety Hiccups AIlergy Cough Hypoglycemia Diarrhea Hypotension AIlergy Allergic rhinitis Edema Secretions Hemorrhoidal
4 Loperamide Loratadine Loratadine-Pseudoephedrine Magic Mouthwash Magnesium Citrate Magnesium Hydroxide Meclizine Melatonin Metaxalone Metoclopramide Metoprolol Tartrate Milk of Magnesia Mineral Oil Morphine Naproxen Normal Saline (Nasal) Ondansetron Oxycodone Oxycodone/Acetaminophen Oxymorphone Phenol-Phenolate Phenylephrine Phenylep-Shark Liv Oil-Mo-Pet Polyethylene Glycol 3350 Polyvinyl Alcohol Prochlorperazine Promethazine Psyllium Quetiapine Fumarate Rizatriptan Benzoate Senna Senna-Docusate Simethicone Sumatriptan Succinate Temazepam Throat Lozenges (Cepastat) Tizanadine Tramadol Tramadol-Acetaminophen Antidiarrheal /Decongestant Mouthwash Laxative Laxative Sedative Antacid Laxative, Lubricant Lubricant / Decongestant Anti-hemorrhoidal Laxative, Osmotic Ophthalmic Agent Typical Antipsychotic Laxative, Bulk-producing Serotonin Receptor Agonist Antiflatulent Serotonin Receptor Agonist Benzodiazepine Diarrhea Oral Mucocitis Dizziness or Vertigo Nasal Dryness Hemorrhoidal Dry Eyes Migraine Flatulence Migraine
5 Trazodone Zaleplon Ziprasidone Mesylate Zolpidem Tartrate Antidepressant
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