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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)
slide8

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