PRN Medication Log Form
Document as-needed medication use quickly and clearly.
Date and Time of Administration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient Name or Identifier
*
Medication Name
*
Dose/Amount Given
*
Route of Administration
*
Please Select
Oral
Injection
Topical
Inhalation
Other
Reason for Administration
*
Person Administering
*
Observed Response or Effect
Additional Notes (optional)
Submit Log
Should be Empty: