How to Fill Out DA Form 4677: Recurring, PRN, and Single Actions

To fill out DA Form 4677, the Therapeutic Documentation Care Plan (Non-Medication), clinical staff work through the form in pencil, block by block, following the instructions in AR 40-66, Section 9-27.¹ The form captures three kinds of non-medication orders during inpatient care: recurring nursing actions, one-time single actions, and as-needed (PRN) actions. Patients do not complete any part of it.

The form’s companion, DA Form 4678, handles medication orders. Together they list the nursing actions and prescribed orders needed to carry out the physician’s plan and reach the care goals documented on DA Form 4256.¹ Despite the “therapeutic” label, DA Form 4677 is not limited to behavioral health; it applies wherever inpatient non-medication orders need documented tracking.

Before You Start

Get the current blank from the Army Publishing Directorate, searching by form number 4677.² Some Army publications require a Common Access Card to download. Check the publication date printed at the bottom of the form to confirm the version. The form originated December 1, 1977; the October 1, 1978 edition is still referenced as acceptable. The Office of The Surgeon General is the proponent agency.

Two rules printed on the form itself govern how you write on it: use pencil, and circle action times. Only clinical staff complete entries. Transcription, verification, and initialing follow the roles described below.

Patient Identification and Administrative Blocks

Start at the top with the Patient Identification block. Enter the standard patient identification data as indicated on the form, then work through the administrative fields:

Allergies: mark “Yes” or “No” and list any known allergies. Non-medication interventions can still trigger reactions (latex, adhesives, dietary items), which is why the block appears on this form.
Primary Diagnosis: enter the current diagnosis, then add any additional diagnoses that significantly affect the patient’s care requirements.
Additional Pages in Use: mark whether supplemental pages are attached and record the page number.

Recurring Nursing Orders

This is the largest section of the form and covers any action performed on a set schedule: wound care every eight hours, physical therapy exercises twice daily, vital sign checks at fixed intervals, and similar repeating tasks. For each identified problem or nursing diagnosis, a nursing order must be written here.¹

Complete each row across:

Order Date: the date of the current order.
Verify By Initialing: the ward clerk or nurse who transcribes the order initials the appropriate block. If a ward clerk or licensed practical nurse transcribes, a registered nurse must also initial the lower portion of the box. The RN’s initials confirm the transcribed order matches the original on DA Form 4256 and is appropriate from a nursing standpoint.
Recurring Actions, Frequency, Time: transcribe the complete order exactly as originally written. This column is only for actions where compliance is repetitive and scheduled.
Date Accomplished: the date the care goal was accomplished or revised.

Discontinuing an Order

For a multiple-line order, draw a diagonal line across the unused blocks. For a single-line order, draw a horizontal line and write “discontinued/date/time/initials” above it. A yellow highlighter is allowed for quick visual recognition of discontinued orders, as long as it does not penetrate the paper or cover the writing.

Nursing-Initiated Orders

When a registered nurse initiates an order rather than transcribing a physician’s, the nurse writes “NIO” followed by their initials in the Verify By Initialing column. Facilities may also print overprints of standard physician or nurse orders on the form under local command policy.¹

Single Actions (Reverse Side)

Turn the form over to reach the Single Actions section. Use it for one-time orders: a specific lab draw, a single imaging study, a one-time patient education session. Each entry needs the order date, transcriber initials (with the same RN verification rule as recurring orders), and the complete order as originally written.

Date and Time to Be Done: when the action should be taken. If timing depends on a future event, write “on call.”
Completed Order: initial the Date/Time/Initial blocks once the action is finished. If the order was not completed, do not initial. Place a circle in the block and explain the reason in the nursing notes.

If a single-action order is not completed within the responsible RN’s tour of duty, it becomes a delayed order and must be transcribed to the Single Actions column for the next shift.

PRN Actions

The PRN section handles orders carried out only when a specific condition arises, such as repositioning a patient on request or applying ice packs for swelling. Record the PRN action, its authorized frequency, and the time and date each time it is performed.

After the Form Is Complete

A completed DA Form 4677 becomes part of the patient’s inpatient treatment record. AR 40-66 groups it with the other standard inpatient documents, including DA Form 4678, DA Form 4256, and related clinical forms.¹ Records are maintained under AR 40-66 and AR 40-68, and access is limited to authorized medical staff.

As military treatment facilities transition to MHS GENESIS, information historically captured on paper forms like DA Form 4677 may be entered and tracked electronically instead. Where behavioral health care is documented, the Behavioral Health Data Portal lets patients self-report data that providers review through real-time dashboards.³

A Note on Substance Abuse Settings

DA Form 4677 does appear in substance abuse treatment when a patient receives non-medication interventions on an inpatient basis, such as structured therapy sessions, group activities, or specific behavioral exercises ordered by a physician. It does not replace the Army Substance Abuse Program’s own forms: DA Form 8003 for enrollment, DA Form 4465 for screening, and DA Form 4466 for progress tracking, all submitted through the Drug and Alcohol Management Information System. Progress notes for ASAP patients are recorded on SF 600 or in an authorized electronic database, not on DA Form 4677. ASAP records are governed by AR 40-66, with access restricted to rehabilitation staff and designated Army Medical Department personnel involved in the patient’s treatment.⁴

1
United States Army. Army Regulation 40-66 – Medical Record Administration and Healthcare Documentation
2
Combined Arms Research Library. Finding Military Publications – Current Pubs
3
Medical Operational Data System. MODS Home
4
United States Army. Army Regulation 600-85 – The Army Substance Abuse Program