Policy and Procedure Overview

Policy and procedure manuals are not light reading.

You don’t take them to the beach and you don’t read them for fun. Given the workload of many community administrators and nurses today, however, you may very well not have time to pour over 355 pages of how-to.

If only you could take in policies and procedures in nice, light, bite-sized helpings. You could knock out an entire manual in no time.

We’re here to help. In this blog series, we’re going to take a look at one small piece of the policies and procedures every assisted living community in Washington must know.

Today, we’ll examine three basic policies and procedures concerning medications.

1. Every prescription and non-prescription med requires a physician’s/prescriber’s order.

Whether you’re an assisted living center, home health agency or hospice, you must have an order for every medication your staff gives or assists in giving. Keep these orders filed away in the resident’s Medication Record.

It may seem silly to require a order for vitamins or laxatives, but the purpose of this provision is ultimately the safety of your residents. Even over-the-counter medications can interact with other drugs, not to mention cause adverse side effects. Requiring a physician’s order or prescriber helps keep everybody (physician, pharmacy, community) aware of every drug that can potentially be present in a resident’s system, preventing unforeseen reactions and preparing a complete record should your resident have a reaction.

2. Every order must be complete and signed before your community may pass any medication.

There are three main points to remember concerning orders:

• Communities must retain orders (paper or electronic), complete with prescriber’s signature, for every medication prescribed to every resident. It is important to note that “visit summaries” are not counted as official orders, because they are not signed.

• By law, orders must include the following:

• Resident name

• Medication name

• Medication strength 


• Dose


• Dosage form.


• Time or frequency of administration


• Route of administration


• Quantity to dispense or duration of therapy

• Prescriber name and signature


• Refill authorization

• Date

• PRN (pro re nata, meaning “as needed”) orders must specify:

• Frequency

• Max daily dosage

• What condition the drug is supposed to treat (pain, sleep, etc.)

Keep in mind that the above is not an exhaustive list. ALC, pharmacy and federal laws and regulations may require more information. You can find these requirements of on the website of the Washington State Legislature.

3. When in doubt, double check

If any one of your staff notices that a prescription seems odd—maybe the order seems inappropriate for the age, allergies or condition of the resident, the dosage is odd, or the medication seems out of place considering the resident’s other medications—they need to verify with the prescriber that the prescription is correct.