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Discussion on the process of how to transcribe doctor's order by nurses in the hospital

Discussion on the process of how to transcribe doctor's order by nurses in the hospital

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  • 1. Transcribing Doctor’s Order By: Pamela M. Veroy RN, MAN
  • 2. 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:
    • Transcribes medical order to nursing Kardex.
    • Fills up instruction sheet, medication cards or ticket and appropriate forms for laboratory and diagnostic requests.
  • 3. CARRYING OUT OF MEDICAL ORDER:
    • If the nurse have any doubt regarding the medical order, she will clarify it with the attending physician who made the order.
    • Affix initials including date and time below it has been carried out already.
  • 4. 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
  • 5.
    • 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.
  • 6. 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:________________________________________
  • 7.
    • 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:_______________________________________________________________________
  • 8.
    • 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:_______________________________________________________________________
  • 9. 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.
  • 10.
    • 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.
  • 11.
    • 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.
  • 12. 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.
  • 13. COLOR CODING OF MEDICINE TICKETS 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 COLOR FREQUENCY TIME WHITE O.D. / STAT PINK BID YELLOW TID BLUE QID/EVERY 4 HOURS GREEN EVERY 6 HOURS RED EVERY 8 HOURS ORANGE PRN HS
  • 14. 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 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)
  • 15. SAMPLE OF MEDICINE TICKET MEDICINE TICKET Date:_________________ Rm no.______ Bed no.______ Name:______________________________________ Drugs Ordered:__________________________________________________________________________________________________ . Dosage:___________________________________________   Frequency:________________________________________   Route:___________________________     Dr:________________ NOD Sig.:_______________
  • 16. Give me the color code….
    • Example:
    • 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. 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-
  • 17. Sample of Medication Sheet – MMGH
    • MEDICATION SHEET
    • NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______
    • NURSE’ FULL NAME/SPECIMEN SIGNATURE
    Date Medication & Treatment Freq PRN STAT
  • 18. 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
  • 19. 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 Cruz Lungs; 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
  • 20. Example: Transcribing Doctors’ Order in Medication Sheet
    • MEDICATION 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 ffl STAT 7-4-08 Lasix 40 mg. I.M. stat 3 pm ffl ffl - Florence Nightale RN
  • 21. 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 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
  • 22. Example: Transcribing Doctors’ Order in Medication Sheet
    • MEDICATION SHEET
    • NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______
    • 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 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
  • 23. Example: Transcribing Doctors’ Order in Medication Sheet
    • MEDICATION SHEET
    • NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______
    • NURSE’ FULL NAME/SPECIMEN SIGNATURE
    Date Medication & Treatment Freq 6 7 8 7-06 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 ffl 10 ffl - Florence Nightale RN
  • 24. 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 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
  • 25. Example: Transcribing Doctors’ Order in Medication Sheet
    • MEDICATION SHEET
    • NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______
    • NURSE’ FULL NAME/SPECIMEN SIGNATURE
    Date Medication & Treatment Freq 6 7 8 7-06 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
  • 26. SAMPLE FORMAT OF MEDICINE TICKET-MMGH
    • Room No. ________________ Date:_______________
    • Name:_____________________________ Age:______________
    • Order:_________________________________________________________
    • Route: ________________________________________
    • Frequency:____________________________________________
    • Dr.___________________________ Sig.__________________________
  • 27. SAMPLE FORMAT OF MEDICINE TICKET
    • Room No. ________________
    • Name:_________________________________________________________
    • Room No.______________________ Bed No._______________________
    • Drug:__________________________________________________________
    • Dosage/Freq:____________________________________________________
    • Route:________________________ NOD:_________________________
  • 28. 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______
  • 29. 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_________
  • 30. 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
  • 31. 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_________
  • 32. Keys 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)
    • A new 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.
  • 33.
    • 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……
  • 34.
    • Drugs just like a sword that has two sharp edges; Whether it heals you, or kill you for just a minute from miscalculation.