Transcribing doctor’s order

Transcribing Doctor’s

OrderBy: Pamela M. Veroy RN, MAN

CARRYING OUT OF MEDICAL ORDER:Objective: To be able to interpret intelligently doctor’s

orderScope: This work instruction is to be done by a nurseMedical 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 h1. Procan SR is the brand name of the drug2. 500 mg is the dosage3. p.o. is the route4. 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.6hRead:____________________________________

____

Example 4: Demerol 75 mg IM q.4h, pain;Read:__________________________________Example 5: Pen-vee K 1 g p.o. 1h pre-op dental

surgeryRead:__________________________________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. / STATPINK BIDYELLOW TID BLUE QID/EVERY 4

HOURS

GREEN EVERY 6 HOURSRED EVERY 8 HOURS

ORANGE PRNHS

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 drugs2. age 6. route3. room no. 7. time frequency4. 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 fflSTAT

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 67-4-08 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 87-06 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 87-06 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……

Drugs just like a sword that has two

sharp edges; Whether it heals

you, or kill you for just a minute from

miscalculation.