2.2. Prescription and over the counter drugs (OTC).


Prescribed Medications

Prescribed medications are those medications that a licensed practitioner (physician, dentist, and advanced registered nurse practitioner) has ordered for treatment of an individual’s particular diagnosis or symptoms. These medications may include controlled/scheduled, non-controlled/scheduled and or over-the-counter.

Prescribed medications may be ordered on an as-needed basis (PRN), on a routine basis, or as a one-time-only order. How the prescribed medication is ordered will determine the Medication Administration Record that will be used to transcribe the order. (i.e. Routinely prescribed medications and one time only orders will be transcribed onto the Routine Medication Administration Record. Medications prescribed on a PRN basis will be transcribed on to the PRN Medication Administration Record).


Over the Counter Medications.

Over the counter medications require a licensed practitioner’s order; however, do not require a prescription. Examples of these medications would be acetaminophen, cough medications, antibiotic ointment, antacids, etc. Over the counter medications must be administered according to the licensed practitioner’s order and documented at the time of administration on an agency-specific record. This record should allow space to determine the effectiveness or ineffectiveness of the medication (i.e. Acetaminophen is given for pain; effective; ineffective). Over the counter medications should be labeled for the person for whom they are ordered.


Controlled/scheduled Medications (narcotics).

         “Controlled/Scheduled medications” are those medications potentially addictive and regulated under the Controlled/Scheduled Substance Act of 1970. Controlled/Scheduled medications CANNOT be obtained without a written prescription from a licensed practitioner. It is very important that controlled/scheduled medications be handled according to the following Drug Enforcement Administration (DEA) recommendations:

  •  kept under double lock and key;
  •  separate from other medications;
  •  signed out each time a dose is administered;
  •  counted, per agency-specific policy, at a minimum daily;
  •  documented accurately to reflect correct count;
  •  disposed of according to DEA requirements.


When controlled/scheduled medicines are prescribed on an as-needed basis (PRN) (i.e. Percodan) they will be transcribed and documented as given on the PRN Medication Administration Record. When a controlled/scheduled substance is given on a routine basis (i.e. Ritalin) it will be transcribed and documented as given on the Routine Medication Administration Record. Controlled/scheduled meditations given on a routine basis must be counted along with controlled/scheduled medication give on a PRN basis.


Controlled substances (narcotics).
  •  A drug subject to restrictions with potential for addiction;
  •  A drug that in moderate doses dulls the senses, relieves pain, can cause stupor, coma, or Convulsions.
  •  Classified into 5 “schedules” class I=most potential for addiction, class V= least potential for addiction. There should be a source of information available to determine if a drug is on the controlled substance list.
  •  It is QMAP responsibility to store controlled substances under double lock, count, and document the count with another QMAP or another QMAP or Qualified Manager at the end of each shift.

        Note: QMAP will need to follow your facility’s policy & procedures for counting liquid medication;

        Note: Possible consequences for drug diversion are… revocation of your QMAP qualification, losing your job, being arrested, being convicted of a crime, and serving time in jail.


        Non-controlled/scheduled medications are all other (both prescribed and over the counter) medications that are not regulated by the DEA, but still, require an order from a licensed practitioner. (Physician, dentist, or ARNP).

All non-controlled/scheduled medications are kept locked according to agency policies and procedures. Agency policies will address all aspects of an individual’s safety in relation to the secure storage of the medication.

        Non-Controlled/Non-Scheduled Medications. All other medications prescribed, including over the counter medication are not considered to be potentially addictive by the DEA. Prescribed and over the counter medications must be locked at a minimum under a single lock. It is very important that the person administering medications read the licensed practitioner’s prescribed orders on medications to determine:

  •  Name;
  •  Time;
  •  Route;
  •  Accurate dosage.


Those medications that are given over-the-counter must be given in accordance with the agency-specific policy related to medication management. OTC medications must be given in accordance with the licensed practitioner’s order which must not require non-licensed staff to use judgment.

Non-licensed personnel will be responsible for educating themselves on medications prior to administration. This can be done by a review of the drug education sheet. This sheet comes from the pharmacy with the medication and will explain why the medication is given and the common side effects of the medication. It is recommended that all employees have an updated drug handbook or drug information/education sheet accessible at all times for review of any prescribed medications and/or over-the-counter medication.

Individual information is imperative to client safety in medication administration/management.


This includes but is not limited to the following:

  •  Individual’s name;
  •  Date of birth;
  •  Sex;
  •  Height;
  •  Weight;
  •  Allergies.