PRN medicines, also called “when required” medicines, and variable-dose medicines are used when needed to treat conditions such as nausea and vomiting, pain, indigestion and more. These medicines only work safely when teams can prove the presence, severity and resolution of pain.
This is where objective, medical-grade devices such as PainChek® can provide a solution by turning staff observations into repeatable data that underpins person‑centred decisions, consistent documentation and robust governance. Documented objective pain assessment is the engine of safer PRN protocols in UK care homes, which can result in fewer hospital admissions and less strain on the system.
Expectations from the CQC
The Care Quality Commission’s updated guidance sets a clear standard for PRN medicines in adult social care. It states that providers must have a formal PRN policy and person-centred PRN protocols that specify:
- What condition the medicine is prescribed for
- Dose instructions – maximum dose in a day, minimum interval between doses and clear instructions for variable doses
- Observable signs or symptoms to look out for (including non-verbal) and when to offer medicine
- Appropriate alternative support to try before medicine
- The order of use when multiple PRNs exist
- When to review or escalate treatment if needed
Use of psychotropics should also follow principles laid out in:
- STOMP (stopping over-medication of people with a learning disability and autistic people)
- STAMP (supporting treatment and appropriate medication in paediatrics)
An area for improvement
Hiral Khoda Vyas, a pharmacist specialising in medicines optimisation in social care and founder of TRIB1 Medicare, has identified several areas for improvement within the current PRN protocols, she states:
“Recent CQC inspection reports continue to highlight PRN and variable-dose medication protocols as a recurring area for improvement in adult social care. A review of several recent reports shows consistent themes, including insufficient detail within protocols, unclear variable dose instructions and gaps in documenting why PRN medicines were administered and whether they were effective.
“Inspectors frequently note that, although protocols may be in place, they do not always provide staff with clear guidance on when medicines should be given, what symptoms to look for or what alternative approaches should be considered first. In some cases, services were unable to demonstrate the rationale for administering PRN medicines or show evidence that outcomes had been monitored and reviewed.
“The updated CQC guidance on ‘when required’ medicines reinforces the need for clear, person-centred PRN protocols. These should describe the condition being treated, the specific signs and symptoms that indicate when the medicine should be used, the dose and maximum daily amount and what actions staff should take before administering medication. The guidance also emphasises documenting both the reason for administration and the outcome, ensuring medicines are used safely and appropriately.”
Hiral supports care providers to strengthen medicines governance, improve medication safety, and promote person-centred medicines use through audits, training and system improvement. Working closely with care teams, GPs and pharmacists, her focus is on embedding practical solutions that support safer and more effective medicines management in social care settings.
How documented pain assessments support PRN protocols
UK guidance requires PRN protocols and documented pain assessments such as PainChek can help to support these protocols which will ultimately lead to more accurate and useful results and fewer hospital transfers for patients.
Supporting safe, accurate administration – As PRN medicines manage intermittent symptoms that are not part of a typical routine, staff need unambiguous instructions to avoid over- or under-dosing and giving doses too close together. Administration should always be based on the identification of symptoms and the need for symptomatic relief. PainChek produces an objective pain score, even when residents cannot self‑report, providing defensible rationale for when to give a PRN analgesic and a baseline for post‑dose review. Evidence shows PainChek’s AI‑enabled facial analysis aligns well with established tools and reduces subjectivity, enabling reliable use by a range of staff.
Ensuring person-centred, individualistic care – protocols must describe what symptoms and cues to look out for, whether the person can request medication and which non-verbal may indicate distress or pain. These indicators may be individual to the resident and should be considered in a person-centred way so medicines are offered appropriately. For example, behaviours such as shouting, crying out or calling for help may represent pain in residents who cannot verbalise discomfort. PainChek standardises the capture of non-verbal indicators through AI facial analytics and observed behaviours, supporting equitable care for those with communication barriers.
Bringing clarity to variable doses – where prescriptions say “1-2” tablets, protocols must state which dose to give and under what circumstances, according to NHS guidance. By embedding PainChek score-linked decision prompts within the protocol using pain assessment tools, teams can choose the appropriate dose range consistently, while still following the prescriber’s instructions.
Improving recording, monitoring and reviewing – High‑quality protocols drive clear documentation, effective monitoring, and regular prescriber review, especially if PRNs are used frequently or not used for long periods. PainChek enables post‑dose reassessment with an objective score so teams can evidence whether the medicine worked, decide whether to repeat/escalate/stop, and escalate for clinical review if pain persists, reducing repeated ineffective dosing and avoidable hospital transfers.
Meeting governance requirements and projecting people – The CQC mandates formal PRN policies, accessible care‑plan protocols, safe storage, authorisation routes and safeguarding when overuse is identified. Psychotropic PRN use should be time‑limited, regularly reviewed, and always preceded by non‑medicinal approaches.
Why PainChek is purpose-built for PRN medicine workflows
People with dementia often cannot self-report their pain and so PRNs risk being given too late, too often or not at all. These can cause uncontrolled pain, distress and further escalations.
PainChek is a regulatory‑cleared medical device for pain assessment used internationally and has independent and real‑world studies to support its reliability and validity in people with dementia. It provides the objective, repeatable data needed to administer the right medicine at the right time and prove it worked.
PainChek can:
- Provide objective pain scores that support safe dosing decisions
- Prevent unnecessary PRN use when scores indicate little to no pain
- Support with structured step-up/step-down as scores can inform stepwise analgesia
- Provide a post-dose effectiveness review with auditable evidence
A five-step PRN and PainChek workflow for care providers to consider
- Baseline assessment – observe symptoms and cues, complete a PainChek assessment to obtain a pain score and record the reason for considering a PRN
- Non-pharmacological first – if the score is low/none, pursue alternatives (fluids, repositioning, environment) and document actions taken
- Administer PRN as per protocol – If pain and PRN is indicated, give the medicine exactly as prescribed; document indication, exact dose (for variable doses), and time
- Post-dose reassessment – Reassess pain in a timely window as per local policy (e.g., within ~1 hour), recording the outcome/effectiveness and any next steps
- Escalate or review – If pain persists, follow escalation instructions in the protocol and contact the prescriber; schedule a review if PRN is used frequently or not used for long periods.
It is important that a PRN or variable-dose protocol is personalised to each resident’s needs and person-centred care.
How this approach reduces hospital admissions
Hospital transfers from care homes are frequently triggered by uncontrolled pain, behavioural escalation, adverse drug events, or failure to evidence clinical decision‑making. When PRN protocols are weak or pain is not objectively assessed, staff often miss early deterioration or over‑treat symptoms, both of which can lead to unnecessary hospital involvement.
PainChek changes this dynamic by providing objective, repeatable pain data at the exact moments when PRN decision‑making matters. This enables earlier, safer and more targeted interventions that prevent deterioration, crisis escalation, and emergency conveyance.
Using PainChek can:
- Prevent untreated pain from escalating into emergency events – CQC requires PRN decisions to be based on clear signs/symptoms, person‑centred cues and timely review. If pain is not recognised—particularly in people with dementia, conditions such as fractures, infections, constipation, or pressure injury pain can worsen until emergency hospital transfer becomes the only option. PainChek objectively identifies moderate and severe pain, even when the resident cannot self‑report, enabling staff to intervene early with PRN analgesia
- Reduce behavioural crises that often lead to 999 calls – Pain is a major contributor to behavioural and psychological symptoms of dementia (BPSD), including agitation, aggression, delirium and refusal of care. A systematic review shows a significant association between pain and multiple BPSD types. CQC highlights that misinterpreting distress as “behaviour” leads to inappropriate psychotropic use, safeguarding concerns, and clinical deterioration. PainChek will confirm whether behaviour is pain driven or not, allowing staff to treat the cause rather than escalating to GPs, paramedics and hospital admission.
- Prevent unnecessary sedative or opioid PRN use – PRN psychotropics and sedatives must be used sparingly and with clear justification as overuse can lead to oversedation, falls and delirium – all common hospitalisation drivers. PainChek prevents this by showing when no pain is present despite behaviours. This protects residents from inappropriate PRN benzodiazepines/opioids.
- Support timely reassessment – this can help to prevent deterioration that triggers emergency escalation. PainChek provides an objective post-dose pain score which allows staff to escalate early if pain persists, before deterioration becomes severe enough to require hospital transfer.
- Provide audit-ready evidence – out-of-hours clinicians often send residents to hospital when documentation is incomplete or unclear, particularly when staff cannot demonstrate whether pain was assessed and the dose was effective. By generating time-stamped, objective assessments with PainChek, care staff can reassure external clinicians that the resident is being safely managed in place.
- Reduce cumulative decline caused by under-treated chronic pain – repeated under-treatment of pain can lead to pressure ulcers, dehydration/malnutrition and higher infection risk – all baseline drivers for ambulance call-outs in care homes. Regular, objective monitoring can ensure chronic pain patterns are identified and managed proactively, reducing hospital-triggering complications.
Improving person-centred care
When care homes combine CQC-compliant PRN protocols with objective pain assessment they gain a complete, defensible, person-centred framework that detects pain before it becomes an emergency, reduces inappropriate sedative/opioid use and related hospital harms and provides evidence that prevents unnecessary hospital transfers.
Hiral Khoda Vyas says:
“Clear guidance for staff, supported by structured assessment tools and good documentation, helps ensure PRN medicines are used appropriately and in the person’s best interests. Embedding these approaches within care planning and medicines management can support safer, more consistent and person-centred care.”
This objective, streamlined approach to care will support care providers while also reducing burden on the healthcare system and unnecessary ambulance call-outs.
