TYPES OF MEDICATION ORDERS

Charold Baer, Bradley R. Williams,

Clinical Pharmacology and Nursing,
Springhouse Pub Co; 1991, pp. 90-94

Under the law, as outlined in the medical practice act of each country, licensed physicians as
well as dentists, podiatrists, and in some countries optometrists may prescribe, dispense, and
administer drugs. In selected circumstances, and within certain protocols, other health care
professionals, such as nurses, pharmacists, or physicians assistants, legally may prescribe and
dispense drugs. Nevertheless, physicians write the vast majority of medication orders. Usually,
pharmacists dispense the drugs, and nurses administer them to patient.
Requirements for medication orders
A medication order may take one of two forms, depending on whether the prescriber is
treating a hospitalized patient or an outpatient. For the hospitalized patient, the prescriber can order
medications, along with all other orders such as those for diet, X-rays, and laboratory work, on the
order sheet in the patients chart. The prescriber also can use a separate medication order sheet. For
outpatients, the prescriber usually writes the medication order on a prescription pad sheet and gives it
directly to the patient. The patient takes the medication order to a hospital or community pharmacy to
be filled.
The prescribers order sheet lists the patients full name for identification purposes. The order
sheet may be stamped with complete identifying information, including the patients birth date, the
hospital number, room number, and date of admission. Health care professionals must take extreme
care in identifying patients, particularly if two or more patients with the same or similar names
appear on the unit.
The prescriber should give the generic or trade name of the drug and its dosage form, if more
than one form of the drug is available. The prescriber should express the dose to be given at each
administration in metric, apothecaries, or household measures and should state the administration
route. The most common administration routes are oral, intramuscular, subcutaneous, and
intravenous, although additional routes involving other body structures and cavities exist. Oral
medications, representing the majority, tend to be the safest, least expensive, and most convenient for
the patient to take.
The prescriber usually states the time schedule for administration as the number of times per
day that the medication is to be administered. Upon noting the time schedule, the nurse then
schedules the specific hours according to how quickly a supply of the medication can be procured,
the medications characteristics, and institutional policies. The medications characteristics,
including its nature and onset and duration of action, primarily determine the schedule. For instance,
if regular, intermittent peak blood concentration levels of antibiotics must be maintained to combat
infections, the prescriber will schedule the drug administration at regular intervals around the clock.
The prescribers signature, along with the date and time of the day the order was written, also should
appear. The date and time often are referred to when the order has an expiration date.
After Rx, which means take thou (prescription, from Latin recipe), the prescriber writes the
drug name, form, and dosage, along with instructions on the amount to be dispensed. After the
abbreviation Sig., which means let it be labeled, the prescriber writes directions to the patient for
taking the medication. The directions are followed by the prescribers signature, address, and
telephone number. Finally, the prescriber indicates the number of times the prescription can be filled.
Types of medication orders
The following seven types of medication orders are routine in the hospital: standard written
orders, single orders, stat orders, p.r.n. orders, standing orders, verbal (or oral) orders, and telephone
orders.

Standard written orders apply indefinitely until the prescriber writes another order to alter
or discontinue the first one. In some cases, the prescriber may specify on the standard written order a
particular termination date. In many cases, hospitals establish policies that indicate how long orders
for certain classes of drugs remain valid. Examples of drugs with controlled termination dates
include narcotic orders for 3 days and antibiotic orders for 7 days. If the patient still needs the drug
after the expiration date, the prescriber must rewrite the order. The prescriber must also rewrite
standard written orders postoperatively if the medications are to be continued.
Single orders are written for medications that are given only once. For example, a prescriber
may order one tetanus toxoid injection for a patient with a laceration or puncture wound who
received a primary tetanus toxoid series more than 10 years earlier.
Calls for medications that are to be administered immediately for an urgent patient problem
are known as stat orders. For instance, a prescriber may order a single dose of an antianxiety drug to
calm an acutely agitated patient.
P.R.N. orders derive their name from a Latin phrase (pro re nata) that means as the
occasion arises. Prescribers write p.r.n. orders for medications that are to be given when needed.
The administration time results from the collaborative judgements of the nurse and the patient.
Sometimes a p.r.n. order delineates the reason for giving the drug. For example, the prescriber may
write Tylenol 650 mg P.O. p.r.n. for a temperature above 101.3 degrees F. (38.5 degrees C.). If an
ordered drug, such as acetaminophen (Tylenol), serves multiple purposes, some hospital policies
state that the nurse administers the drug only for the specific condition mentioned in the order. Under
such a policy, the nurse would not give Tylenol only for fever if the patient complained of a
headache but had no fever. Other institutions allow the nurse to determine when to administer a p.r.n.
drug. When administering a p.r.n. medication, the nurse should describe in the patients record the
reason for its use and its degree of subsequent effectiveness.
Also known as protocols, the standing orders establish guidelines for treating a particular
disease or set of symptoms. These orders require considerable judgement and expertise in assessing
the patients need for the medication and any dose-related adverse drug reactions that might occur.
Special care areas of the hospital, such as the coronary care unit, routinely establish standing
orders that apply to such drug therapies as morphine sulfate for chest pain and anxiety, lidocaine
(Xylocaine) for ventricular tachycardia. Hospitals also may institute medication protocols that
specifically designate drugs that a nurse may not give.
Verbal orders Medication orders given orally rather than in writing are known as verbal
orders. Health care professionals try to avoid using verbal orders because such orders can lead to
miscommunication. In urgent situations, the nurse should write and sign the order dictated by the
prescriber. Then the nurse should repeat the order aloud for the prescribers verification and request
the prescriber to spell the drug name if necessary. The prescriber should sign the verbal order that the
nurse has written as soon as possible. The institution should have a policy that dictates the time
period in which the prescriber must sign a verbal order. If a patient experiences hypoglycemic or
insulin shock and the prescriber instructs the nurse to prepare immediately 50 ml of 50% glucose for
I.V. administration, the nurse should show the prescriber the label in the empty glucose vial while
simultaneously stating the drugs name and handing the syringe to the prescriber. Such actions allow
the prescriber to confirm the accuracy of the drug and its dose.
Telephone orders Verbal orders given to a nurse by a prescriber over the telephone may
result in dangerous errors from mechanical problems involving the telephone and from the lack of
nonverbal communication cues between the prescriber and nurse. Nurses should avoid telephone
order; the nurse should ask another nurse to monitor the call on an extension telephone. By
monitoring the call, the second nurse can confirm the order. Unfortunately, nurses cannot always
include such monitoring on the clinical unit. Besides verifying the drug name given during a
telephone order, the nurse should repeat orally the individual digits of the dose. The nurse then writes
the order, indicating that it was a telephone order. Later, the prescriber must cosign the order within
the time period established by institutional policy.