Interpretation and Implementation of Range, Titration, and PRN Orders in Hospice

Mary Lynn McPherson, PharmD, BCPS; Karen S. Kaiser, PhD, RN, AOCN; Cameron Burns, PharmD

Disclosures

Journal of Hospice and Palliative Nursing. 2005;7(5):289-298. 

In This Article

Conclusion

As hospice and palliative care organizations approach an upcoming JCAHO survey, they should be aware of how to accept, interpret, and implement range, titration, and PRN orders. Agencies need to determine the required elements of each type of order and develop policy. During policy development, consideration should be given to safe provision of patient comfort. Staff involved with medication prescribing, administration, and providing guidance to patients/families about taking medications should be educated on the policy to ensure consistency and optimize patient safety. A sample policy is shown in the Appendix. A corresponding example table that can be distributed to practitioners is provided in Table 1 . Staff should be given an opportunity to practice accepting, interpreting, and implementing PRN, range, and titration orders. This should include the following: (a) how to assess the patient, (b) the required elements of the medication order, (c) how to implement the order, (d) education of the patient/family/caregiver regarding how to implement a PRN or range order, and (e) what to document in their symptom diary and the documentation requirements of the nurse. At the time of JCAHO survey, such individuals may be interviewed by the Joint Commission surveyors to determine adherence to policy and discuss concomitant safety risks. Of note, when there is inconsistent interpretation during the actual JCAHO survey, documentation related to healthcare professional education has been requested by the Joint Commission.

To prepare for a joint commission survey on range, titration, and PRN orders, the following recommendations are offered. Mock surveys should include questions about interpretation of range, titration, and PRN orders to determine if interventions are implemented consistently by different practitioners. Orders should be periodically audited to determine if they meet the minimum criteria set by the agency. Adverse event reporting should capture any events that are attributable to range doses and is recommended by the joint commission.[8] Such preparations will assist the organization in providing safe, effective care while using analgesics and other medication orders that are deemed to be a safety risk.

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