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Transcribing doctors order
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Transcript of Transcribing doctors order
CARRYING OUT OF MEDICAL ORDER:Objective: To be able to interpret intelligently doctor’s
order
Scope: This work instruction is to be done by a nurse
Medical Order – an order (written or verbal) made by the physician pertaining care or management.
Work Instructions Detail:
1. Transcribes medical order to nursing Kardex.
2. Fills up instruction sheet, medication cards or ticket and appropriate forms for laboratory and diagnostic requests.
CARRYING OUT OF MEDICAL ORDER:
1. If the nurse have any doubt regarding the medical order, she will clarify it with the attending physician who made the order.
2. Affix initials including date and time below it has been carried out already.
How to interpret drug orders?
Make sure that the 5 rights are there in the doctor’s order.
- right name of the drug
- right name of patient
- right dosage
- right time, frequency
- right route by w/c the drug administered
Example 1:Procan SR 500 mg p.o. q. 6 h
1. Procan SR is the brand name of the drug
2. 500 mg is the dosage
3. p.o. is the route
4. q. 6h is the frequency
This order means; Give 200 milligrams of Procan SR orally every 6 hours.
How to interpret drug orders?
Example 2:Dilantin 100 mg p.o. t.i.d.
Read:________________________________________
Example 3: procaine penicillin G 400,000 U IM q.6h
Read:________________________________________
Example 4: Demerol 75 mg IM q.4h, pain;
Read:__________________________________
Example 5: Pen-vee K 1 g p.o. 1h pre-op dental surgery
Read:__________________________________
Other Doctor’s order for treatment:
1. 2/3 strength solution Ensure. Give 90 ml qh for 5 hours via NG tube.
Read:_______________________________________________________________________
2. 5/8 strength solution Isomil 36 ml via NG tube hourly for 8 feedings.
Read:_______________________________________________________________________
3. Acetaminophen 240 mg. p.o. q4-6h p.r.n., pain or T>38⁰C.
Read:_______________________________________________________________________
3 Common Errors in Transcribing Medication
1. Incorrect interpretation of order due to misunderstanding of traditional time.
• SITUATION:• A physician ordered a mild sedative for an anxious Patient
who is scheduled for a colonoscopy in the morning. The order read “Valium 5 mg orally at 6:00 x 1 dose.”
• The evening nurse interpreted that single dose order to be scheduled for 6 o’clock PM along with the enema to be given to the patient.
• The doctor meant for the Valium to be given at 6 o’clock AM to help the patient relax prior to the actual test.
• 2. Failing to clarify incomplete orders.• SITUATION:• Suppose a physician ordered Pepcid tablet p.o. h.s. for a
patient with an active duodenal ulcer. You will note there Is no dosage listed.
• The nurse thought the dosage came in only one strength, added 20 mg to the order, and sent it to the pharmacy. The pharmacist prepared the dosage written on the physician’s order sheet.
• Two days later, during rounds, the physician noted that the patient had not responded well to the Pepcid. When ask about the Pepcid, the nurse explained that the patient had received 20 mg at bedtime. The physician informed the nurse that the patient should have received the 40 mg. tablet.
• 3. Not checking the correct dosage.• SITUATION:• A nurse flushed a triple central venous catheter (an
IV with three ports). According to hospital policy, the nurse was to flush each port with 10 ml of normal saline followed by 2 ml of heparin flush solution in the concentration of 100 units/ml.
• The nurse mistakenly picked up a vial of heparin containing 10,000 units/ml. Without checking the label she prepared the label with all three ports. The patient received 60,000 units of heparin instead of 600 units.
Critical Thinking Analysis
Reading the labels of medications is critical, Make
sure that the drug you want is what you have or hand before
you prepare it.
COLOR CODING OF MEDICINE TICKETSCOLOR FREQUENCY TIME
WHITE O.D. / STAT
PINK BID
YELLOW TID
BLUE QID/EVERY 4 HOURS
GREEN EVERY 6 HOURS
RED EVERY 8 HOURS
ORANGE PRN
HS
6-6/12-12
6-12-66-10-2-6
6-10-2-6-10-2
6-12-6-12
6-2-10
9 PM
MEDICINE TICKETObjective: To be able to guide the nurse to follow the
doctor’s written order indication the drug to be given the frequency of doses the amount of each dose and the method of administration.
Scope:1. name of patient 5. name of drugs
2. age 6. route
3. room no. 7. time frequency
4. date 8. doses
(doctors’ name, NOD signature)
SAMPLE OF MEDICINE TICKET
MEDICINE TICKETDate:_________________ Rm no.______ Bed no.______Name:______________________________________Drugs Ordered:__________________________________________________________________________________________________ .Dosage:___________________________________________ Frequency:________________________________________ Route:___________________________ Dr:________________ NOD Sig.:_______________
Give me the color code….
Example:1. Lasix 40 mg. IM stat --------------------2. Motrin 600 mg. p.o. b.i.d. ------------3. Tranxene 7.5 mg p.o. q.i.d. -----------4. Tylenol w/ codeine gr. I p.o.
q. 4h p.r.n. for pain ---------------------5. Inderal 50 mg. p.o. t.i.d. --------------6. Amoxicillin susp. 100mg p.o.
q. 6 hrs. ------------------------------------7. Oxacillin sodium 0.25 g p.o. q. 8 hrs-
Sample of Medication Sheet – MMGHMEDICATION SHEET
NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______
NURSE’ FULL NAME/SPECIMEN SIGNATURE
Date Medication & Treatment
Freq
PRN
STAT
SAMPLE DOCTORS’ SHEET_____________________________________________________________________
First Name Given Name M.I.
WARD:_________ROOM NO._______BED NO._______PHYSICIAN_________________
______________________________________________________________________
Date and Time: Time Remarks:
Ordered: Signature: ______
PROGRESS NOTES DOCTOR’S ORDER
SAMPLE DOCTORS’ SHEET_Panduco Pedro__________________________P.____________
Last Name Given Name M.I.
WARD:_Wing A_ROOM NO. 212 BED NO._2__PHYSICIAN__Dr. Roberto de la Cruz_
______________________________________________________________________
Date and Time: Time Remarks:
Ordered: Signature: _____
PROGRESS NOTES DOCTOR’S ORDER
7-04-2008 - Give Lasix 40 mg. I.M. stat
(+) edema lower - Start Motrin 600 mg. p.o. b.i.d.
extremities ¥æ€
(+) rales on boths Dr. de la CruzLungs; RR-26/min; BP 110/80 2:45 p.m.
7-05-08 - Tylenol w/ codeine gr. I p.o. q. 4h p.r.n. for pain
Complaint of headache ¥æ€
5:30 p.m. Dr. de la Cruz
Example: Transcribing Doctors’ Order in Medication SheetMEDICATION SHEET
NAME: _Penduco, Pedro__ Room:_212_ Bed No:_2_ Chart No.:_000123_
NURSE’ FULL NAME/SPECIMEN SIGNATURE
Date Medication & Treatment
Freq 4 5 6
7-4-08 Motrin 600 mg. p.o. b.i.d. 6 ffl
6 ffl
7-5-08 Tylenol w/ codeine gr. I p.o. PRN
q. 4h p.r.n. for pain 6pm ffl
STAT
7-4-08 Lasix 40 mg. I.M. stat 3 pm ffl
ffl - Florence Nightale RN
SAMPLE OF DOCTORS’ SHEETPanduco Pedro__________________________P.____________
Last Name Given Name M.I.
WARD:_Wing A_ROOM NO. 212 BED NO._2__PHYSICIAN__Dr. Roberto de la Cruz_
______________________________________________________________________
Date and Time: Time Remarks:
Ordered: Signature: _____
PROGRESS NOTES DOCTOR’S ORDER
7-06-08 - Tranxene 7.5 mg p.o. q.i.d.
Leukocytes –CBC result - Oxacillin sodium 0.5 g p.o. q. 8 hrs-
- D/C Motrin ¥æ€
9:30 a.m. Dr. de la Cruz
Example: Transcribing Doctors’ Order in Medication SheetMEDICATION SHEET
NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______
NURSE’ FULL NAME/SPECIMEN SIGNATURE
Date Medication & Treatment
Freq 4 5 6
7-4-08 Motrin 600 mg. p.o. b.i.d. 6 ffl D C 7-6
6 ffl
7-5-08 Tylenol w/ codeine gr. I p.o. PRN
q. 4h p.r.n. for pain 6pm ffl
STAT
7-4-08 Lasix 40 mg. I.M. stat 3 pm ffl
ffl - Florence Nightale RN
Example: Transcribing Doctors’ Order in Medication SheetMEDICATION SHEET
NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______
NURSE’ FULL NAME/SPECIMEN SIGNATURE
Date Medication & Treatment
Freq 6 7 8
7-06 Tranxene 7.5 mg p.o. q.i.d. 6
10 ffl
2 ffl
6
Oxacillin sodium 0.5 g p.o. q. 8 hrs 6
2 ffl10
ffl - Florence Nightale RN
SAMPLE OF DOCTORS’ SHEETPanduco Pedro__________________________P.____________
Last Name Given Name M.I.
WARD:_Wing A_ROOM NO. 212 BED NO._2__PHYSICIAN__Dr. Roberto de la Cruz_
______________________________________________________________________
Date and Time: Time Remarks:
Ordered: Signature: _____
PROGRESS NOTES DOCTOR’S ORDER
7-06-08 - Tranxene 7.5 mg p.o. q.i.d.
Leukocytes –CBC result - Oxacillin sodium 0.5 g p.o. q. 8 hrs-
- D/C Motrin ¥æ€
9:30 a.m. Dr. de la Cruz
7-07-08 - Continue Oxacillin 0.5 g p.o. q8h for 4 doses and D/C
¥æ€
12:30 a.m. Dr. de la Cruz
Example: Transcribing Doctors’ Order in Medication SheetMEDICATION SHEET
NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______
NURSE’ FULL NAME/SPECIMEN SIGNATURE
Date Medication & Treatment
Freq 6 7 8
7-06 Tranxene 7.5 mg p.o. q.i.d. 6 ffl
10 ffl ffl
2 ffl
6 ffl
Oxacillin sodium 0.5 g p.o. q. 8 hrs 6 ffl
1 – 2 – 3 - 4 2 ffl ffl
10 ffl
ffl - Florence Nightale RN
SAMPLE FORMAT OF MEDICINE TICKET-MMGH
Room No. ________________ Date:_______________
Name:_____________________________ Age:______________
Order:_________________________________________________________
Route: ________________________________________
Frequency:____________________________________________
Dr.___________________________ Sig.__________________________
SAMPLE FORMAT OF MEDICINE TICKET
Room No. ________________
Name:_________________________________________________________
Room No.______________________ Bed No._______________________
Drug:__________________________________________________________
Dosage/Freq:____________________________________________________
Route:________________________ NOD:_________________________
SAMPLE FORMAT OF MEDICINE TICKET-MMGH
Room No. _212-2__ Date:___7-06-08______
Name:___Penduco, Pedro__________ Age:__22_________
Order: __Tranxene 7.5 mg p.o. q.i.d. ____
Route: __per orem_____
Frequency:_______6 – 10 – 2 - 6______________________
Dr._Dr. de la Cruz_______ Sig.___ffl______
SAMPLE FORMAT OF MEDICINE TICKET
Date __7-06-08_____
Name:___Penduco, Pedro__________________________
Room No.__ 212____ Bed No.__2____
Drug:_Amoxicillin susp.100mg p.o. q. 6 hrs._
Dosage/Freq:__6 – 12 -6 - 12________________________
Route:___oral______
NOD:____ffl_________
Irregularities in Transcribing MT
• If the order is PRN with varied time frequencies• If the order is stat and then with regular time
frequency• To indicate dosage; you can write – name of drugs,
strength (dosage), time frequency• Stat order to be administered less than 1 hr. on a• Medicine ordered with a series of doses should also
write no. of dosage done on the ticket
Example situation
Date __7-06-08_____
Name:___Penduco, Pedro__________________________
Room No.__ 212____ Bed No.__2____
Drug:_Amoxicillin 500mg IVTT q. 6 hrs. x 6 doses_then shift to p.o.
Dosage/Freq:__6 – 12 -6 - 12__________________
Route:___IVTT______
1-2-3-4-5-6 NOD:____ffl_________
Keys to Remember:1. Never transcribe doctors’ order in a medicine ticket with
erasures or tampered.
2. Always write legibly, neatly, and correctly.
3. Do not recycle the used medicine ticket. (as much as possible)
4. A new doctors’ order is a new medicine ticket.
5. Endorsed to your charged nurse the old ticket that has changed order in; (increase/decrease dosage; route)
6. Do not revise/rephrase what have written in the doctors’ order. Rewrite completely what have written in the order.
7. If in doubt; check your ticket from the doctors’ order sheet first before in the medication sheet.
8. Arrange your drugs according to their color coding if for 1 patient with lots of drugs in different frequencies/timing.
9. Make an indication/marks on the medicine ticket for stat orders; to prevent from administering twice.
10. Signing the medication sheet as prompt as possible after administering/given a due medicines.
11. Do not sign the medication sheet in advance; without administering the drugs yet. Especially IVTT meds.
12. Always coordinate with the charge nurse with regards to new orders; new drugs ordered; etc.
13. Be mindful always……