INSTRUCTIONS FOR HOW TO FILL OUT THE PSYCHOTROPIC PRN PROTOCOL TEMPLATE
Follow these instructions to fill in the Psychotropic PRN Protocol template (Not Used for Behavior Control)
Read through these instructions while you are filling in the template.
When you are done, delete these pages of instructions before printing and using the protocol.
Psychotropic PRN Protocol
Feel free to change the title to reflect the person and their specific medication.
Name of Person Supported: Insert the person’s first and last name.
Date protocol written: Insert date.
Date protocol expires: Insert date.
All intrusive protocols must be time-limited. The signatures of approval are valid for this date
range, which must be no longer than one year. After this time the protocol must be reviewed and
re-approved by the prescribing medical doctor if the prn is still necessary.
A separate protocol must be written for each psychotropic PRN. PRN medications that are not
psychotropic (ex. stool softeners) require a different type of protocol; see template for Nonpsychotropic PRN protocols.
Type of Psychotropic Medication
Drug name: Insert name of medication (ex. lorazepam) and brand name of drug (ex. Ativan).
Dosage:
Insert dosage of the PRN that person is prescribed to receive at one administration.
Type the maximum number of PRN administrations per day.
Brief description of Person Supported
Provide a brief description of the person, including any factors relevant to the need for the
psychotropic PRN (e.g., medical diagnoses, psychiatric diagnoses, physical factors, social or
emotional factors). This should not be a comprehensive description, but should include sufficient
detail to give the reader a sense of the person and their need for the PRN.
Purpose of the Psychotropic Medication
Outline the specific challenging behaviours for which this PRN is being administered. Provide
specific definitions and/or descriptions of the behaviours. Be sure to note how the behaviour(s)
present(s) a danger to self or others or to property.
Rationale for Psychotropic PRN
Outline briefly the reason for this particular medication and the circumstances under which it will
be given (for example, it might be thought that the person experiences anxiety and the PRN is for
anxiety reduction).
In addition, specifically state how and why this is the least restrictive, most effective intervention
(e.g., it is used to avoid physical restraint or police involvement).
Outline the involvement of the person and/or their substitute decision-maker in the choice of this
particular PRN and/or the PRN protocol.
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Outline safeguards to prevent misuse of PRN (e.g., PRN will be used only when de-escalation
techniques have proven ineffective; safeguards in place to make sure the PRN is not use for staff’s
convenience).
Method of Psychotropic Medication Administration
Describe the exact criteria that determine when to administer the medication. What behaviours
must the person show and for how long before administration? An accompanying escalation
continuum and/or crisis plan should be developed and attached. This plan must outline the steps
taken to prevent the use of PRN by supporting the person when she displays precursors of
challenging behaviour.
Include the name of the medication, the drug brand name, and the administration route. Also, if
there is provision for additional doses, how much time must elapse between PRN administrations?
What is the maximum number of repeat administrations in what period of time?
Risks and Benefits of using the PRN
Describe the risks associated with the PRN used (e.g., side effects). Describe the benefits of using the PRN
(e.g., avoid more intrusive procedures, avoid police involvement).
Regular monitoring of wellbeing of person
Include instructions of regular monitoring of person’s wellbeing during the PRN administration.
Evaluation of Psychotropic Medication Effectiveness
Describe the PRN is to be monitored

Describe immediate monitoring for effectiveness and potential harmful side effects.
Documentation must include the time the PRN was administered, the Support Workers
involved, and a method of assessing the effectiveness of the PRN. See sample data sheet
attached.

Describe longer-term monitoring; that is, how often will the use of the PRN and the need for
the PRN be evaluated? Who will do this evaluation? What are the criteria to determine that
the PRN protocol is no longer necessary or is still necessary or is still necessary but must
change? If it is still necessary, what is the date of the next evaluation?

Outline any plans of the eventual fading or elimination of the PRN medication. This might
include reference to an additional behavioural consultation or counseling being pursued to
help teach coping skills or anxiety management or anger management skills.
Regular updating regarding the use of PRN
Describe how the person supported and/or person acting on his behalf will be updated regularly regarding
the use of PRN.
Training and supervision on PRN administration
Describe briefly how the Direct Support Professionals will be trained and supervised on the use of
PRN.
Approval of & Consent to the Psychotropic Medication Protocol
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All of the persons listed on the signature page must sign this PRN protocol. Note that only the
professional is approving the use of this protocol, while the others simply consent to its
implementation.
Approval of & Consent to the Psychotropic Medication Protocol
1) The healthcare professional prescribing the medication must approve this protocol and review it
once a year.
_________________________________
Name & Profession
_____________________ _________________
Signature
Date
Date of next review: ___________________
All of the following persons must sign this protocol to indicate that they have read and understand
it and consent to its implementation.
2) _______________________________
Name of Person Supported
_____________________
Signature
(if appropriate)
_________________
Date
and/or
3) _______________________________
Name of Substitute Decision Maker
_____________________
Signature
(if appropriate)
_________________
Date
4) _______________________________
Name of person who wrote protocol
_____________________
Signature
_________________
Date
5) _______________________________
Name of Program Manager
_____________________
Signature
_________________
Date
6) _______________________________
Name of Area Manager
_____________________
Signature
_________________
Date
7) For persons younger than 18 years old, the appropriate ministry must sign.
_________________________________
Name
_____________________
Signature
_________________
Date
ERC review
The local Ethical Review Comittee (ERC) must review and approve psychotropic medication
protocols, and document this review in the ERC meeting minutes. The ERC reviews need to occur
every 3 (three) months.
Date of last review: __________________ Date of next review: ___________________
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Document the response to ERC recommendations.
Direct Support Professionals’ Review
Direct Support Professionals will review the protocol at least every 6 (six) months. Add a signature
page for Direct Support Professionals’ review.
____________________
Name
_____________________
Signature
_______________
Date
_____________
Date of review
____________________
Name
_____________________
Signature
_______________
Date
_____________
Date of review
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Psychotropic PRN Data Sheet
Drug: _______________________ Dosage: _________ Date of prescription: ___________
Instructions: Every time this PRN is used, it must be documented on this data sheet, as well as on an
Occurence/Incident Report, in support notes, and on the MARS.
Date
Time PRN
Effectiveness measure: how well did
administered the PRN meet its stated purpose?
How long did it take (e.g., 5, 15, 20
minutes)?
Side effects
observed
Support
Workers
involved
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