Transcribing Doctors Order

By: Pamela M. Veroy RN, MAN

CARRYING OUT OF MEDICAL ORDER:

Objective: To be able to interpret intelligently doctors 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 doctors 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 Doctors 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>38C. 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 oclock PM along with the enema to be given to the patient. The doctor meant for the Valium to be given at 6 oclock 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 physicians 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 TICKETS

COLOR WHITE PINK YELLOW BLUE GREEN RED ORANGE FREQUENCY O.D. / STAT BID TID QID/EVERY 4 HOURS EVERY 6 HOURS EVERY 8 HOURS PRN HS TIME

6-6/12-12
6-12-6 6-10-2-6 6-10-2-6-10-2 6-12-6-12 6-2-10

9 PM

MEDICINE TICKET
Objective: To be able to guide the nurse to follow the doctors 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 TICKET Date:_________________ 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 MMGH

MEDICATION SHEET NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______ Date Medication & Treatment Freq

PRN STAT

NURSE FULL NAME/SPECIMEN SIGNATURE

SAMPLE DOCTORS SHEET

_____________________________________________________________________ First Name Given Name M.I. WARD:_________ROOM NO._______BED NO._______PHYSICIAN_________________ ______________________________________________________________________ Date and Time: Time Remarks: Ordered: Signature: ______ PROGRESS NOTES DOCTORS 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 7-04-2008 (+) edema lower extremities (+) rales on boths
Lungs; RR-26/min; BP 110/80

DOCTORS ORDER - Give Lasix 40 mg. I.M. stat - Start Motrin 600 mg. p.o. b.i.d. Dr. de la Cruz 2:45 p.m.

7-05-08
Complaint of headache

- Tylenol w/ codeine gr. I p.o. q. 4h p.r.n. for pain

5:30 p.m. Dr. de la Cruz

Example: Transcribing Doctors Order in Medication Sheet

MEDICATION SHEET NAME: _Penduco, Pedro__ Room:_212_ Bed No:_2_ Chart No.:_000123_ Date
7-4-08

Medication & Treatment Freq

Motrin 600 mg. p.o. b.i.d.

4 5 6

6 6

7-5-08

Tylenol w/ codeine gr. I p.o. q. 4h p.r.n. for pain

PRN 6pm

STAT
7-4-08 Lasix 40 mg. I.M. stat

3 pm

NURSE FULL NAME/SPECIMEN SIGNATURE

- Florence Nightale RN

SAMPLE OF 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 7-06-08 Leukocytes CBC result DOCTORS ORDER - Tranxene 7.5 mg p.o. q.i.d. - Oxacillin sodium 0.5 g p.o. q. 8 hrs- D/C Motrin 9:30 a.m. Dr. de la Cruz

Example: Transcribing Doctors Order in Medication Sheet

MEDICATION SHEET NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______ Date
7-4-08

Medication & Treatment Freq

Motrin 600 mg. p.o. b.i.d.

4 5 6 D C
7-6

6 6

7-5-08

Tylenol w/ codeine gr. I p.o. q. 4h p.r.n. for pain

PRN
6pm

STAT
7-4-08 Lasix 40 mg. I.M. stat 3 pm

NURSE FULL NAME/SPECIMEN SIGNATURE

- Florence Nightale RN

Example: Transcribing Doctors Order in Medication Sheet

MEDICATION SHEET NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______ Date
7-06

Medication & Treatment Freq

Tranxene 7.5 mg p.o. q.i.d.

6 7 8

6 10 2 6

Oxacillin sodium 0.5 g p.o. q. 8 hrs

2
10

NURSE FULL NAME/SPECIMEN SIGNATURE

- Florence Nightale RN

SAMPLE OF 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 7-06-08 Leukocytes CBC result DOCTORS ORDER - Tranxene 7.5 mg p.o. q.i.d. - Oxacillin sodium 0.5 g p.o. q. 8 hrs- D/C Motrin 7-07-08 9:30 a.m. Dr. de la Cruz - Continue Oxacillin 0.5 g p.o. q8h for 4 doses and D/C 12:30 a.m. Dr. de la Cruz

Example: Transcribing Doctors Order in Medication Sheet

MEDICATION SHEET NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______ Date
7-06

Medication & Treatment Freq

Tranxene 7.5 mg p.o. q.i.d.

6 7 8

6
10 2

6
Oxacillin sodium 0.5 g p.o. q. 8 hrs

123-4

2
10

NURSE FULL NAME/SPECIMEN SIGNATURE

- Florence Nightale RN

SAMPLE FORMAT OF MEDICINE TICKET-MMGH

Room No. ________________

Name:_____________________________

Date:_______________
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__

Name:___Penduco, Pedro__________

Date:___7-06-08______
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._________

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:_____________

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:_____________

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

Drugs just like a sword that has two sharp edges; Whether it heals you, or kill you for just a minute from miscalculation.