1. Drug Orders & Prescriptions
Chapter 8

2. 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

3. 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 ed directly to the pharmacy

4. 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

5. 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

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

7. Abbreviations
See Common Abbreviations in Prescriptions found on Page in textbook

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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Graphic Sheet

16. 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

17. 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

18. 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

19. MAR

20. 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

21. 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

22. 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

23. 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