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Seniors and People With Disabilities Medication Administration Record for PRN’S SDS 0812B Page 1 of 2 (01/05) Resident: Physician: Date Hour Medication Reason Results Hour Initials Signature 1 2 3 4 Instructions A. Write initials in appropriate box at the time medication is given. B. Circle initials when medication is refused. C. State reason for refusal in the narrative. D. State reasons PRN is given, and the results. E. Date and initial all changes. 5

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Page 1: Medication Administration Record for PRN’SSeniors and People With Disabilities Medication Administration Record for PRN’S SDS 0812B Page 1 of 2 (01/05) Resident: Physician: Date

Seniors and People With Disabilities

Medication Administration Record for PRN’S

SDS 0812B Page 1 of 2 (01/05)

Resident: Physician:

Date Hour Medication Reason Results Hour

Initials Signature

1 2 3 4

Instructions A. Write initials in appropriate box at the

time medication is given. B. Circle initials when medication is refused. C. State reason for refusal in the narrative. D. State reasons PRN is given, and the

results. E. Date and initial all changes. 5

Page 2: Medication Administration Record for PRN’SSeniors and People With Disabilities Medication Administration Record for PRN’S SDS 0812B Page 1 of 2 (01/05) Resident: Physician: Date

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