Drug Orders & Prescriptions Chapter 8

Drug Order Drug Order (Medication Order): Order for a drug written on the agency’s (hospital, nursing center) physician’s order form for a patient or resident

Prescription Prescription: Drug order for a person leaving the hospital or nursing center Prescriptions are taken to a local pharmacy to be filled Can be called in, faxed or emailed directly to the pharmacy

Parts of a Drug Order All drug orders and prescriptions must contain: Person’s full name Date Drug name Route of Administration Dose Frequency Duration of order Doctor’s (or prescriber’s) signature

Types of Drug Orders 4 types of drug orders: Stat Order Single Order Immediately A single does of a medication is administered immediately Single Order Drug is to be given at a certain time & only one time Standing Order Drug is to be given for a certain number of doses or for a certain number of days PRN Order Drug is to be administered when necessary or as needed based on the patient’s needs Only to be administered by nurse or physician Cannot be administered by Medication Assistant

Ordering Methods Doctors can give drug orders in several ways: Written Order Verbal Order Telephone Order Faxed Order Electronic Order

Abbreviations See Common Abbreviations in Prescriptions found on Page 90-91 in textbook

Measurements Roman Numerals Weights Measurements See Page 93 in your textbook for complete listing

Administration Times See examples of Standard Administration Times on page 93 in your textbook

Prescription Labels Prescription Labels must contain the following pieces of information: Person’s name, address & phone number Pharmacy name, address & phone number Prescription number Date the prescription was filled Original date of the prescription Doctors name Brand name of the drug Generic name of the drug Manufacturer’s name Drug dosage Amount in the container How often to take the drug Directions for use Warnings Number of refills allowed Expiration Date

Medical Record Forms Medical Record/Chart/Clinical Record: Written account of a person’s condition and response to treatment & care Method to share information amongst healthcare team Permanent legal document Medical records consist of many forms, including Admission form Health history Physical exam results Doctor’s orders Progress notes Graphic sheet Flow sheet Lab & X-ray reports IV therapy record Respiratory record Consultation reports Surgical & Anesthesia reports Assessments Consent forms Medication Administration record PRN or unscheduled medication record

Medical Records (continued) Health team members record information on forms for their departments. Other team members read this information. This information explains the care provided & response Medical record policies: Who records When to record Abbreviations Correcting errors Ink color Signing entries

Privacy All healthcare professionals have an ethical and legal duty to keep a patient’s information confidential If you do not provide care to a given patient, you have no right to review the person’s chart….to do so is an invasion of privacy Patients and residents that a right to the information contain within their medical record Report any medical request to a nurse

Graphic Sheet Graphic sheet: Used to record measurements and observations made daily, every shift, or 3-4 times a day. Information may contain: Vitals signs (temperature, pulse, respirations, BP) Weight Intake & Output Bowl movements Doctor visits You may need to check a graphic sheet prior to administering a medication

Graphic Sheet

Progress Notes Progress Notes: Describe the care given and the person’s response and progress. Sometimes called nurse’s notes Nursing team uses this form to record: Patient signs & symptoms Information about treatments Information about all PRN medications Recorded right after administered Vitals are taken before administration Patient’s condition is monitored after administration Information about patient or resident teaching or counseling Procedures performed by the doctor Visits by other health team members

Progress Notes Date Time Progress Notes 19-Mar 1700 Out with family for dinner. Jane Does, LPN   1930 Returned from eating accompanied by her son. States she had a pleasant time. Mary Smith, NAC 20-Mar 900 In bed complains of headache. T98.4 orally, radial pulse 72 and regular, respirations 18 and unlabored. BP 134/84 left arm lying down. Alice Jones, RN notified of resident complain and vital signs. Ann Adams, NAC 910 In bed resting. States she has had a headache for about 1/2 hour. Denies nausea and dizziness. No other complaints. PRN Tylenol given. Instructed resident to use signal light if headache worsens or other symptoms occur. Alice Jones, RN 945 Resting quietly. Denies headache at this time. T 98.4 orally, radial pulse 70 and regular, respirations 18 and unlabored. BP 132/84 left arm lying down. Alice Jones, RN

Medication Administration Record Medication Administration Record (MAR) Lists all medications to be given to a person Often times referred to as the medication profile May be computerized or handwritten Medication grouping: Scheduled medications: Scheduled on a regular basis Parenteral medications: Injectables STAT medications: Administered AT ONCE after receiving orders Pre-operative medications: Prior to surgery PRN medications: As needed

MAR

MAR (continued) MAR provides space for recording the tie the drug was administered and who gave it Recording is done immediately after administering the drug Initial the time when the drug was administered Write your initials, signature and title MAR includes a place to not the patient’s allergies Prior to administering a medication always check for allergies Report to the nurse if the person is allergic to a medication ordered

Medication Records in ALF Residents in ALF manage & take their own medication is able Some residents need assistance, in which case a medication records are maintained Records include: Person’s name Drug name, dose, directions and route of administration Date & time of administration Date and time assistance was provided Signature on initials of person assisting

PRN or Unscheduled Medication Record State of Washington does not allow a MA-C to administer PRN medications Some agencies use PRN medications or unscheduled medications. The following information is recorded: Date & Time Drug given Dose given Route Reason for giving the medication Person’s response

The Kardex Kardex: Card file that summarizes information found in the medical record, including: Medication Treatments Diagnoses Routine care measures Equipment & special needs Not a formal, legal part of the medical record