Medication 4h7060
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Transcribing Doctor’s Order By: Pamela M. Veroy RN, MAN
CARRYING 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 istered
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 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 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 doctor’s written order indication the drug to be given the frequency of doses the amount of each dose and the method of istration.
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
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 (+) rales on boths Lungs; RR-26/min; BP 110/80
7-05-08 Complaint of headache
¥æ€ Dr. de la Cruz 2:45 p.m.
- Tylenol w/ codeine gr. I p.o. q. 4h p.r.n. for pain ¥æ€ 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
Medication & Treatment Freq
7-4-08
Motrin 600 mg. p.o. b.i.d.
6 6
7-5-08
4 5 6
Tylenol w/ codeine gr. I p.o.
PRN
q. 4h p.r.n. for pain
6pm
ffl ffl
ffl
STAT 7-4-08
Lasix 40 mg. I.M. stat
3 pm ffl
NURSE’ FULL NAME/SPECIMEN SIGNATURE
ffl - 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
DOCTOR’S ORDER - Tranxene 7.5 mg p.o. q.i.d. - 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 Sheet MEDICATION SHEET NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______ Date
Medication & Treatment Freq
7-4-08
Motrin 600 mg. p.o. b.i.d.
6 6
7-5-08
4 5 6
Tylenol w/ codeine gr. I p.o.
PRN
q. 4h p.r.n. for pain
6pm
ffl
D C
7-6
ffl
ffl
STAT 7-4-08
Lasix 40 mg. I.M. stat
3 pm
ffl
NURSE’ FULL NAME/SPECIMEN SIGNATURE
ffl - Florence Nightale RN
Example: Transcribing Doctors’ Order in Medication Sheet MEDICATION SHEET NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______ Date
Medication & Treatment Freq
7-06
Tranxene 7.5 mg p.o. q.i.d.
6 7 8
6 10
ffl
2
ffl
6 Oxacillin sodium 0.5 g p.o. q. 8 hrs
6
2
ffl
10
NURSE’ FULL NAME/SPECIMEN SIGNATURE
ffl - 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
DOCTOR’S ORDER - Tranxene 7.5 mg p.o. q.i.d. - 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 Sheet MEDICATION SHEET NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______ Date
Medication & Treatment Freq
7-06
Tranxene 7.5 mg p.o. q.i.d.
6 7 8
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
NURSE’ FULL NAME/SPECIMEN SIGNATURE
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__________
Order: __Tranxene
Age:__22_________
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 istered 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 : 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 istering twice. 10. g the medication sheet as prompt as possible after istering/given a due medicines. 11. Do not sign the medication sheet in advance; without istering 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.
CARRYING 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 istered
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 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 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 doctor’s written order indication the drug to be given the frequency of doses the amount of each dose and the method of istration.
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
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 (+) rales on boths Lungs; RR-26/min; BP 110/80
7-05-08 Complaint of headache
¥æ€ Dr. de la Cruz 2:45 p.m.
- Tylenol w/ codeine gr. I p.o. q. 4h p.r.n. for pain ¥æ€ 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
Medication & Treatment Freq
7-4-08
Motrin 600 mg. p.o. b.i.d.
6 6
7-5-08
4 5 6
Tylenol w/ codeine gr. I p.o.
PRN
q. 4h p.r.n. for pain
6pm
ffl ffl
ffl
STAT 7-4-08
Lasix 40 mg. I.M. stat
3 pm ffl
NURSE’ FULL NAME/SPECIMEN SIGNATURE
ffl - 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
DOCTOR’S ORDER - Tranxene 7.5 mg p.o. q.i.d. - 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 Sheet MEDICATION SHEET NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______ Date
Medication & Treatment Freq
7-4-08
Motrin 600 mg. p.o. b.i.d.
6 6
7-5-08
4 5 6
Tylenol w/ codeine gr. I p.o.
PRN
q. 4h p.r.n. for pain
6pm
ffl
D C
7-6
ffl
ffl
STAT 7-4-08
Lasix 40 mg. I.M. stat
3 pm
ffl
NURSE’ FULL NAME/SPECIMEN SIGNATURE
ffl - Florence Nightale RN
Example: Transcribing Doctors’ Order in Medication Sheet MEDICATION SHEET NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______ Date
Medication & Treatment Freq
7-06
Tranxene 7.5 mg p.o. q.i.d.
6 7 8
6 10
ffl
2
ffl
6 Oxacillin sodium 0.5 g p.o. q. 8 hrs
6
2
ffl
10
NURSE’ FULL NAME/SPECIMEN SIGNATURE
ffl - 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
DOCTOR’S ORDER - Tranxene 7.5 mg p.o. q.i.d. - 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 Sheet MEDICATION SHEET NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______ Date
Medication & Treatment Freq
7-06
Tranxene 7.5 mg p.o. q.i.d.
6 7 8
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
NURSE’ FULL NAME/SPECIMEN SIGNATURE
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__________
Order: __Tranxene
Age:__22_________
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 istered 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 : 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 istering twice. 10. g the medication sheet as prompt as possible after istering/given a due medicines. 11. Do not sign the medication sheet in advance; without istering 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.
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