Rules for Transcribing Medication Orders

Transcribing medication orders is when someone transfers a physician's prescription order to a medication administration record (MAR). With medication transcriptions, the transcriber must follow certain rules to ensure accuracy and compliance. Transcription of prescriptions must be accurate for patient safety.

Regulatory Agencies Board of Nursing writes regulations that ensure safe, effective medication administration and transcription so that any trained employee can read the orders clearly and with full understanding. Prescribing a Medication When a physician prescribes medication, she has determined or diagnosed a particular problem. The transcription of the prescription is the second most important step in the medication process because any minor error could lead to trouble for the patient taking the medicine. Transcription always receives heavy scrutiny. Requirements Only a physician or licensed practitioner can write a medication order. The transcriber must make sure it is complete, including all of the following information (a) Date (b)Name of medication (c) How much to take (d)How to take it (e)How often (f) and the physician's or practitioner's signature. Transcribing The transcriber must transfer the order to an MAR exactly as the order reads and in legible writing. If other employees cannot read it, medication errors can result that can be fatal to the patient.

Order Changes/Discontinued Medications Discontinuing or changing medications happens frequently, and with each change, the transcriber will have to adjust the MAR to reflect new orders. The transcriber must highlight the old medication indicating the doctor is no longer giving that medication. If the new order stops or discontinues a medication, the transcriber highlights the medication, noting the date and writing DC, for discontinued, in the margin or highlighted area. You are Accountable Medication errors due to improper transcription account for roughly half of adverse reactions in patients, which is why it is so important to transcribe medication orders correctly. The person who transcribes medication orders is accountable for any inaccuracies.

When Does Nursing Malpractice Occur?

Like malpractice involving doctors, nursing malpractice happens when a nurse does not fulfill duties in a way that a normally competent nurse in the same situation would -- and that negligence injures the patient. (Keep in mind that not every mistake or unfortunate event that happens in a hospital or doctor's office rises to the level of negligence.

Doing or Saying Nothing When Action Is Required

Nurses are often the frontline for a patient. If the patient has a sudden emergency, a nurse may be liable if he or she doesn't take appropriate immediate steps. This may involve actions like administering a medication or calling for help. Similarly, a nurse is under a duty to monitor a patient's condition. If the nurse notices something of concern, or should notice it, then the nurse may be liable for malpractice for not notifying the attending doctor.

Improper Administration of Medication

Administering medication according to the doctor's orders is a common nursing task. If the nurse fails to follow the orders, she or he will be liable for malpractice if the patient is injured. The nurse may also be liable for negligently following

MEDICATION ADMINISTRATION

PRINCIPLES OF MEDICATION ADMINISTRATION Ten Rights of drug administration 1. The Right Medication when administering medications, the nurse compares the label of the medication container with medication form. The nurse does this 3 times: a. Before removing the container from the drawer or shelf b. As the amount of medication ordered is removed from the container c. Before returning the container to the storage 2. Right Dose when performing medication calculation or conversions, the nurse should have another qualified nurse check the calculated dose 3. Right Client an important step in administering medication safely is being sure the medication is given to the right client. a. To identify the client correctly: b. The nurse check the medication administration form against the clients identification bracelet and asks the client to state his or her name to ensure the clients identification bracelet has the correct information. 4. Right Route if a prescribers order does nor designate a route of administration, the nurse consult the prescriber. Likewise, if the specified route is not recommended, the nurse should alert the prescriber immediately. 5. Right Time a. the nurse must know why a medication is ordered for certain times of the day and whether the time schedule can be altered b. each institution has are commended time schedule for medications ordered at frequent interval

c. Medication that must act at certain times are given priority (e.g insulin should be given at a precise interval before a meal) 6. Right documentation Documentation is an important part of safe medication administration a. The documentation for the medication should clearly reflect the clients name, the name of the ordered medication,the time, dose, route and frequency b. Sign medication sheet immediately after administration of the drug. 7. Teach your patient about the drug he is receiving. 8. Take a complete patient drug history (There is risk of adverse drug reaction when a number of drug are taken or when patient is taking alcohol drink). 9. Find out if the patient has any drug allergies. 10. Be aware of potential drug drug or drug- food interaction. To protect your patient and your license, fallow these guidelines for avoiding medication errors.

A FUNDAMENTAL RULE OF SAFE DRUG ADMINISTRATION IS: NEVER ADMINISTER AN UNFAMILIAR MEDICATION 1. Keep the Narcotics in locked place. 2. Use only medications that are in clearly labeled containers. Relabeling of drugs are the responsibility of the pharmacist. 3. Return liquid that are cloudy in color to the pharmacy. 4. Before administering medication, identify the client correctly. 5. Do not leave the medication at the bedside. Stay with the client until he actually takes the medications.

6. The nurse who prepares the drug administers it. Only the nurse prepares the drug knows what the drug is. Do not accept endorsement of medication. 7. If the client vomits after taking the medication, report this to the nurse in-charge or physician. 8. Preoperative medications are usually discontinued during the postoperative period unless ordered to be continued. 9. When a medication is omitted for any reason, record the fact together with the reason. 10. When the medication error is made, report it immediately to the nurse in-charge or physician. To implement necessary measures immediately. This may prevent any adverse effects of the drug.

GENERAL PRINCIPLES IN PARENTERAL ADMINISTRATION OF MEDICATIONS 1. Check doctors order. 2. Check the expiration for medication drug potency may increase or decrease if outdated. 3. Observe verbal and non-verbal responses toward receiving injection. Injection can be painful.client may have anxiety, which can increase the pain. 4. Practice asepsis to prevent infection. Apply disposable gloves. 5. Use appropriate needle size. To minimize tissue injury. 6. Plot the site of injection properly. To prevent hitting nerves, blood vessels, bones. 7. Use separate needles for aspiration and injection of medications to prevent tissue irritation.

8. Introduce air into the vial before aspiration. To create a positive pressure within the vial and allow easy withdrawal of the medication.

9. Allow a small air bubble (0.2 ml) in the syringe to push the medication that may remain. 10. Introduce the needle in quick thrust to lessen discomfort. 11. Either spread or pinch muscle when introducing the medication. Depending on the size of the client. 12. Minimized discomfort by applying cold compress over the injection site before introduction of medicati0n to numb nerve endings. 13. Aspirate before the introduction of medication. To check if blood vessel had been hit. 14. Support the tissue with cotton swabs before withdrawal of needle. To prevent discomfort of pulling tissues as needle is withdrawn. 15. Massage the site of injection to haste absorption. 16. Apply pressure at the site for few minutes. To prevent bleeding. 17. Evaluate effectiveness of the procedure and make relevant documentation. Intravenous.

Right Drug preparation and Administration

Check the label of the container for the drug name, concentration, and route of appropriate administration. Check the patients Chart, Kardex, and Medication record. Check medication to be mixed in one syringe with a list approved by the hospital. Normally all drug mixed in a single syringe should be administer with in 15 min. after mixing. ALWAYS CHECK the content of the syringe for clarity and the absence of any precipitation. If either is present DO NOT administer the content of the syringe.

Check pt. identity EVERY TIME a medication is administered. Do approach the pt. in a firm but kind manner that conveys the feeling that cooperation is expected.

Do adjust pt. to the most appropriate position. Do remain with the pt. to be certain that all medication have been swallowed. Do use every opportunity to teach the pt. and family about the drug being administered. Do give simple and honest answer or explanation to the pt. regarding the medication and treatment. Do use plastic container, medication cup, medicine dropper, oral syringe or nipple to administer oral medication to an infant or small child. Do not prepare or administer a drug from the container that is not properly label or from a container where the label is not fully legible. Do not give any medication prepared by individual other than the pharmacist .ALWAYS check the drug name, dosage, frequency, and route of administration against the order. Do not attempt to administer any drug orally to a comatose patient. Do not leave a medication at the pt. bedside to be taken LATER remain with the individual until the drug is taken and swallowed. Before Discharge 1. Explain the proper method of taking prescribe medication to the pt. 2. Stress the need for punctuality in the administration of medication and what to do if a dosage is missed. 3. Provide the pt. with written instruction reiterating the medication Names, Schedule, and how to attain refills. The write the instruction in a language understood by the pt. and use LARGE BOLD LETTR when necessary.