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Writing Orders and Prescription Writing. Resident Orientation Course 2012 Presented by Dr. Siadi. Outline. Admission Orders Medication Orders Discharge Orders Prescription Writing. Admission Orders.

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Writing orders and prescription writing

Writing Orders and Prescription Writing

Resident Orientation Course 2012

Presented by Dr. Siadi


Outline
Outline

  • Admission Orders

  • Medication Orders

  • Discharge Orders

  • Prescription Writing


Admission orders
Admission Orders

  • All patients need a standard conventional set of orders when they are admitted or transferred between floors within the hospital

  • Gives direction to nurses on patient care

  • Useful phase to remember is:

    • ADC VANDALISM or ADC VAAN DISML


Adc va ndalism
ADCVANDALISM

  • Admit to Internal Medicine service under Dr. ____

  • Diagnosis: list in order of priority

  • Condition: good, stable, fair, guarded, critical

  • Vitals: every 4 hours, every shift, routine

    • Allergies: List medication and food allergies


Adc va ndal ism
ADC VANDALISM

  • Nursing: I/O’s, daily weight, neuro-check, seizure precautions

  • Diet: regular, low sodium, clear liquid, nothing per oral (NPO), diabetic

  • Activity: bed rest, up to chair, ambulate 3 times daily

  • Labs/Imaging: CBC and chemistry every morning


  • Adc vandalism
    ADC VANDALISM

    • IV Fluids: Normal saline 100 cc/hr x 24 hrs

    • Special request: example commode to bedside

    • Medications: List the medications that you want patient on for example antibiotics, DVT prophylaxis

    • Always put parameters for the nurse to call you

      • House officer calls: Notify house officer if BP > 150/100, temperature > 101°F


    Other important things for admission orders
    Other Important Things for Admission Orders

    • Can also place on the admission orders:

      • Consults: Consult specific specialty services (Cardiology)

      • Code status: Full code, Do not resuscitate (Country specific)

    • Write legible orders as others have to read them !

    • You must sign your name, the service you are with and your phone number (attending should co-sign in 24 hrs)


    • Admit to: Internal Medicine Service under Dr. Siadi, resident Dr. ____

    • Diagnosis: Congestive Heart Failure

    • Condition: Stable

    • Vitals: q 4 hours

    • Allergies: Penicillin

    • Nursing: Please record I/O’s, record daily weights, Fluid restrict to 1.5 liters per day

    • Diet: Low sodium

    • Activity: Out of bed as tolerated

    • Labs: CBC, Chemistry panel, Chest X-ray now; Chemistry panel twice daily

    • IV Fluids: None

    • Medications:

    • Furosemide 40 mg IV q 12

    • Coreg 6.25 mg q 12

    • Lipitor 80 mg po daily

    • ASA 325 mg po daily

    • Lisinopril 20 mg po daily

    • Instructions: Please call house officer if BP < 100/50 > 150/00, Temp > 101.4°F, RR <10 >20, HR <55 > 100

    • Consult: Cardiology

      • Dr. John Smith

      • Internal Medicine Resident

      • Phone number: 070-777-8888


    A medication order
    A Medication Order

    • Always place the patients name, patient identification number (SSN)

    • Place weight of patient and allergies on the order sheet

    • Drug name, strength, dose, route, frequency

      • Lisinopril 20 mg po (by mouth) daily

    • Sign your name, service and phone number

    • Date and time your order

    www.csuchico.edu


    Writing proper medication orders
    Writing Proper Medication Orders

    • Always, always write the drug name (generic), strength, route, and frequency of use

    • Most medications have an indefinite duration unless you specify otherwise

      • You need to write if a medication is as needed (PRN) and qualify the order (Tylenol 650 mg po q 4 hrs as needed for pain or temp > 101.4°F

      • Antibiotics need to have a duration of time associated with them


    Writing proper medication orders1
    Writing Proper Medication Orders

    • Changes to prior orders should be written on a new order sheet

    • Do not use trailing zeros (e.g. 1.0 mg)

    • Always write preceding zeros (e.g. 0.1 mg)

    • Always be specific with what you want done and if any questions call the nurse or pharmacist


    Discharge orders sample orders
    Discharge Orders - Sample Orders

    • Discontinue: all lines and tubes

    • Discharge home with: Instruction on what the patient leave the hospital with for example the discharge narrative

    • Discharge diagnosis: What was the final diagnosis?

    • Condition: What is the patient’s condition at discharge?

    • Activity: Describe what kind of activity they are able to do?


    Discharge orders sample orders1
    Discharge Orders - Sample Orders

    • Diet: Make recommendations on diet such as low sodium

    • Medications: List all the medications that you want the patient to take

      • Make sure the new medications are identified for the patient !!

    • Follow-up: Specify whom you want the patient to follow-up and when

    • Instructions: Specify and special instructions for the patient


    Abbreviations with medication orders
    Abbreviations with Medication Orders

    • PO= per oral, PR = per rectal, gtt = drops, IV = Intravenous

    • qd= once a day

      • Abbreviation is no longer allowed on charts

      • Should write out the word daily or qDay instead

    • bid = twice a day

    • tid= three times a day

    • qid = four times a day


    Abbreviations with medication orders1
    Abbreviations with Medication Orders

    • q12= every 12 hours (not the same as bid)

      • q12 means midnight and noon

      • Bid means you give the medication when the patient wakes up and prior to bed

    • qAM= every morning

    • qHS = every evening

    • qAC = before every meal

    • prn= as needed


    Medication writing examples
    Medication Writing Examples

    • Furosemide 40 mg po bid

    • Ceftriaxone 1 gram IV q 12° x 14 doses – first dose stat

    • Prednisone 40 mg po daily x 2 days, then 20 mg po daily x 2 days

    • Maalox 30 ml q 4-6° prn dyspepsia


    Prescription writing
    Prescription Writing

    • Should be written on an appropriate prescription pad

    • Controlled substances, including narcotics and benzodiazepines should be prescribed by licensed physicians

    www.essentialtremor.org


    Prescription writing example
    Prescription Writing Example

    • Patient’s name: Date:

    • Drug Name: Lisinopril 20 mg

    • Sig(Instructions): 1 tab by mouth daily

    • Disp (dispense): # 90 (ninety) tabs

    • Refills: 3


    Any questions
    Any Questions ??

    www.jeffkorhan.com


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