Writing Orders and Prescriptions

Educational Objectives The student will be able to write standard admission orders The student will be able to write correct medication orders The student will be able to write complete discharge orders The student will be able to write clear and legible prescriptions

Outline Admission Orders Medication Orders Discharge Orders Prescription Writing

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 -These are orders used to admit the patient to the hospital

ADC VANDALISM 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 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 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 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 Always place the patients name, patient identification number if one is available (hospital, service number etc.) 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 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 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 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 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 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 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 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 Should be written on an appropriate prescription pad Controlled substances, including narcotics and benzodiazepines should be prescribed by attending or licensed physicians www.essentialtremor.org

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 ?? www.jeffkorhan.com