Transcribing Physician’s Orders By Nancy Knight
Physician’s Orders • Admission Orders – these are the orders that come with the patient when they are admitted to the facility. These are usually the most lengthy and contain multiple types of orders • Routine Orders – these orders relate to routine activities for the patient, such as diet, activity, routine medication changes or diagnostic testing • Stat Orders – these are orders the physician wants put into action immediately
Prioritizing Orders • Read all the orders when received • Stat orders must always be taken care of immediately. • Scan the list of orders to identify stat orders-take care of these immediately. • Routine orders are not as urgent but remember that nothing happens for the patient until the order is transcribed.
What is in an order? • Name of test, medication, etc. that is needed • Dose or amount if applicable • Time to be done • Method or mode of administration • Other documentation • Example: CT scan of abdomen with oral contrast in AM
What do I do with an order? • Ask yourself: • Who all needs to know? • How do I let them know? • When should I let them know? • What forms will be needed to document this event?
Transcribing an Order • Read through all orders. • Prioritize orders by stat and routine. • With routine orders, prioritize by when needed.
Diagnostic Orders • Orders for lab, x-ray or other diagnostic tests must be scheduled with the appropriate department. • Facilities vary in whether this is done electronically or by phone. • Must know what the tests are in order to schedule them with the appropriate department. • Some tests need patient preparation prior to testing, you are responsible for seeing that this protocol is also put into action. • For example: a Fasting Blood Sugar requires that the patient be NPO after midnight. Instructions to Nursing services must also be given in addition to scheduling with the laboratory.
Activity of Daily Living Orders • ADL orders include special instructions in regard to diet, activity, elimination, etc. • These are typically communicated to the Charge nurse and on the Nursing Care Plan. • Special equipment needs should be communicated to Central Supply. • Dietary orders need to be communicated to Dietary Services as well as to the nursing staff.
Medication Orders • Should include the “Six Rights” • Right Medication • Right dose or amount • Right patient • Right time • Right method or mode of administration • Right documentation
Medication Orders • Transmit order to the pharmacy • Prepare medication administration instructions for Nursing staff • Include medication instructions on routine Medication Administration Record if a routine med. • If PRN or one time medication it is recorded in the nurses notes when given by the licensed nurse.
Transcribing Physician’s Orders • Let’s practice