Transcribing
Doctor’s
Order
By: Pamela M. Veroy RN, MANCARRYING 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
administeredExample 1:Procan SR 500 mg p.o. q. 6h
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 1g p.o. 1h pre-op dental
surgery
Read:
Other Doctor’s order for treatment:
1. 2/3 strength solution Ensure. Give 90 ml gh
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>38°C.
Read:3 Common Errors in Transcribing Medication
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. fora
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 mi! of norma!
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.\Te'al
| *
WHITE
PINK
YELLOW
BLUE
GREEN
RED
ORANGE
0.D. / STAT
BID
TID
QID/EVERY 4
HOURS
EVERY 6 HOURS
EVERY 8 HOURS
PRN
HS
6-6/12-12
6-12-6
6-10-2-6
6-10-2-6-10-2
6-12-6-12
6-2-10
9PMMEDICINE TICKET
Objective: 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
Date:__
Name:__
Drugs
Ordered:
MEDICINE TICKET
Rm no.__ Bed no.
Dosage:.
Frequency:
Route:__
Dr:,
—— NOD Sig.:E
a
2
3
4.
oD
Give me the color code....
xample:
. Lasix 40 mg. IM stat -- -
. Motrin 600 mg. p.o. b.i.d
. Tranxene 7.5 mg p.o. q.i.d.
. Tylenol w/ codeine gr. | p.o.
q. 4h p.r.n. for pain ----
Inderal 50 mg. p.o. t.i.d.
. Amoxicillin susp. 100mg p.o.
. Oxacillin sodium 0.25 g p.o. q. 8 hrs-Date Medication &
Treatment
Freq
PRN
STAPROGRESS NOTES DOCTOR’S ORDERPROGRESS NOTES
7-04-2008
(+) edema lower
extremities
(+) rales on boths
‘Lungs; RR-26/min; BP 110/80
7-05-08
Complaint of headache
DOCTOR’S ORDER
- Give Lasix 40 mg. I.M. stat
- Start Motrin 600 mg. p.o. b.i.d..
¥e€
Dr. de la Cruz
2:45 p.m.
- Tylenol w/ codeine gr. | p.o. q. 4h p.r.n. for pain
¥e€
5:30 p.m. Dr. de la CruzDate
7-4-08
75-08
7-4-08
Medication &
Treatment
Motrin 600 mg. p.o. b.i.d.
Tylenol w/ codeine gr. | p.0.
4.4h p.r.n. for pain
Lasix 40 mg. LM. stat
ffl- Florence Nightale RN
PRN
6pm
STAT
3pm ffl
MURSE FULL NAME; areKiMer EMAL UNE:elec es)
7-06-08
* Leukocytes -CBC result
DOCTOR’S ORDER
- Tranxene 7.5 mg p.o. q.i
- Oxacillin sodium 0.5 g p.o. q. 8 hrs
-D/C Motrin ¥ae€
9:30 a.m. Dr. de la CruzDate Medication &
Treatment
7-4-08 Motrin 600mg. po. bid.
7-5-08 Tylenolw/ codeine gr. | p.0.
49. 4h p.nn. for pain
7-408 Lasix 40 mg. ILM. stat
ffl- Florence Nightale RN
Freq
PRN
6pm
STA
3pmDate Medication &
Treatment
7-08 —Tranxene 7.5 mg p.o. q.i.d.
Ovacillin sodium 0.5 g p.o. 4. 8 hrs.
ffl- Florence Nightale RN
6
10_—sffl
ffl
6
2 fflPROGRESS 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 ¥a€
9:30 a.m. Dr. de la Cruz
- Continue Oxacillin 0.5 g p.o. q8h for 4 doses and D/C
¥e€
12:30 a.m. Dr. de la CruzDate Medication &
Treatment
7-08 —Tranxene 7.5 mg p.o. q.i.d.
Ovacillin sodium 0.5 g p.o. 4. 8 hrs.
1 2-3-4
ffl- Florence Nightale RN
Freq
10
= =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.__fflSAMPLE 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: fflIrregularities 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. ona
Medicine ordered with a series of doses should also
write no. of dosage done on the ticketExample 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: fflKeys to Remember:
Never transcribe doctors’ order in a medicine ticket with
erasures or tampered.
Always write legibly, neatly, and correctly.
Do not recycle the used medicine ticket. (as much as
possible)
Anew doctors’ order is a new medicine ticket.
Endorsed to your charged nurse the old ticket that has
changed order in; (increase/decrease dosage; route)
Do not revise/rephrase what have written in the doctors’
order. Rewrite completely what have written in the order.
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.