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NUC0520 NUC140 Medication Order Transcription > Doctors Orders > Flashcards

Doctors Orders Flashcards

1
Q

What types of Doctors Orders are there?

A
  • Diagnostic procedures
  • Medication order
  • Therapy order
  • Dietary order
  • Activity order
  • Nursing care / Treatment order
  • Discharge order
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2
Q

What colour ink does the doctor write the order in?

A

Black ink

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3
Q

What 3 things must the doctor do to complete the order?

A

Notes the date and time the order was written, and signs the entry

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4
Q

How does the physician alert the nursing staff that an order has been written?

A

The physician will flag the chart

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5
Q

What should you do with a patient’s chart prior to placing it back onto the chart rack?

A

Check for new orders

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6
Q

What 3 things do you need to remember with a Physician Order?

A
  • If the new orders are recorded at the top of the Physician’s Order Sheet, check the previous page to see if the orders are continued from it.
  • If orders are recorded near the bottom of the sheet, make diagonal lines across the bottom so no new orders will be recorded there.
  • Transcription of Physicians’ Orders is the single most responsible task you perform as a Unit clerk. An error may result in a patient being harmed or his/her recovery time being extended. You owe it both to the patient and the hospital to complete the transcription procedure promptly, accurately, and thoroughly.
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7
Q

What are the 5 types of transcription errors?

A
  1. Errors of Omission
  2. Errors of Interpretation
  3. Errors in the Selection of the Patient’s Imprinter Card or Errors in Selection of the Patient’s Name on the Computer Screen
  4. Errors in the Selection of the Patient’s Kardex Form
  5. Errors in Reading the Doctor’s Poor Handwriting
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8
Q

What are some ways you can prevent an error of omission during transcription?

A
  • Always read and understand each word of the doctors’ orders. If in doubt, check with the RN or the doctor.
  • Always use symbols. It is especially important for you to write the symbol after you have completed each step of transcription.
  • When new orders are recorded at the top of the doctor’s order sheet, check the previous order sheet to see if these orders are continued from the previous page.
  • If the set of orders finishes near the bottom of the doctor’s order sheet, cross through the remaining space with diagonal lines.
  • Always record the signing off information on the line directly below the doctor’s signature to avoid leaving space in which future orders could be written.
  • Always check for new orders before returning a chart from the counter or elsewhere to the chart rack.
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9
Q

How can you avoid an error of interpretation during transcribing?

A

• When in doubt about the correct interpretation of doctors’ orders, always check with the RN or doctor.

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10
Q

How can you prevent an error in the selection of the patient’s imprinter card or by selecting the patient’s name on the computer screen?

A

• Always compare the patient’s name and the hospital number you have imprinted on the requisition form or selected on the computer screen with the same information on the patient’s chart cover. Never select the imprinter card or computer labels by the patient’s room number only.

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11
Q

How can you preventing selecting the wrong patient’s Kardex form?

A

• Always compare the patient’s name and the doctor’s name on the Kardex form with the same information on the label on the patient’s chart cover. Do not use the information on the doctors’ order sheet. It may have the wrong information on it. Never select by using room number alone. If the patient has been transferred the room number imprinted on chart forms may no longer be correct.

Note: Many people on the nursing staff use the Kardex for a quick reference and may flip too another patient’s Kardex form while you are transcribing orders. If this should occur, check to see that the Kardex file is returned to the patient’s Kardex form that you are working on.

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12
Q

How can you prevent errors in reading the doctor’s poor handwriting?

A

• When you cannot read an order because of the doctor’s handwriting, refer to the progress record form on the chart. The orders are often recorded on this form also and using this information may assist you in reading the orders on the physician’s order form. If the order remains unclear, ask the doctor who wrote it for clarification. Don’t waste time asking others. They will be guessing also. If a doctor has a reputation for poor handwriting, ask him or her to read the orders to you before leaving the unit.

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13
Q

What are the 3 records used in transcribing?

A
  1. Physician’s Order
  2. Medication Administration Record (MAR)
  3. Kardex prn – K or Kx
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14
Q

What 5 things could be included on medication orders?

A
  1. New Orders
  2. Changes (∆)
  3. Re-orders (R/O)
  4. Discontinuations (D/C)
  5. Repeats (MR)
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15
Q

K

Symbol

A

Indicates the order has been transcribed on the patient’s Kardex. It also indicates that a discontinued order has been erased from the Kardex.

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16
Q

RMO

Symbol

A

Indicates diagnostic tests, treatment, or supplies have been ordered

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17
Q

MAR

Symbol

A

Indicates transcription of a medication order onto the Medication Administration Record

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18
Q

FAXED

Symbol

A

Indicates that the Physician’s Order sheet was faxed to the Pharmacy. Record the date and time the PO was faxed.

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19
Q

I/C or O/E

Symbol

A

Indicates diagnostic tests, treatments, bloodwork, etc. have been entered in the computer

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20
Q

APPT

Symbol

A

Indicates an appointment has been booked with another department

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21
Q

DEPT AWARE

Symbol

A

Indicates department has been notified

22
Q

RN AWARE

Symbol

A

Indicates RN has been advised

23
Q

PAGED

Symbol

A

Indicates Physician, individual/department have been paged

24
Q

NOTED / DONE

Symbol

A

Indicates NUC has read the order and it has been transcribed/processed accordingly.

25
Q

VM

Symbol

A

Voice message

26
Q

What shall you keep in mind when entering the correct doctor info?

A
  • If you are unsure about the proper way to use the correct Doctor on the computer then you should check with registration.
  • If you enter the wrong Doctor on-the-order - the correct doc will not get the results, which will lead to a delay in care.
  • Medical imaging is the most time consuming/expensive error to correct for mis entered information
  • If Doctors get results from things they did not order, they toss them. They are too busy to ensure that the correct Doctor receives their results for the follow-up.
  • Meditech/CAIS/Cerner is not perfect - make sure we get the correct Doctor.
  • Occasionally errors are made with Doctor mnemonics.
  • Whoever writes the order - is the Doctor to be entered into the computer.
  • If you cannot tell who ordered it, ask the nurse, someone will know who that Doctor was.
  • The preference is that Doctors use a stamp; if not, use their ID number.
27
Q

What is the MAR used to record?

A
  • Drug
  • Dosage
  • Route
  • Frequency
  • Miscellaneous
  • Administration times of all medications ordered for a patient
28
Q

Are MARs manually initiated or computerized?

A

Both

29
Q

When is a manual MAR initiated on the nursing unit?

A

For new patients or if there is a shortage of space to record meds on the computerized MAR

30
Q

What information must be on each MAR?

A
  • Addressograph or label
  • Date
  • Page #
  • Medications are noted as routine or prn
  • Allergies (must be noted in red ink)
31
Q

What is the time frame for each MAR?

A

24 hours

32
Q

Where are the MARs kept?

A

In the MED room in bed number order in the medication binder

33
Q

When does the Pharmacy print the updated MARs?

A

Every 24 hours. They are sent to the nursing units typically around 2100

34
Q

Who is responsible for checking Physicians Orders with updated MARs?

A

RN

35
Q

Where is the MARs filed?

A

Today’s MAR and the previous days MAR are filed in the MAR binder with today’s MAR on top. All other outdated MARs are filed in the patient’s chart.

36
Q

What happens to the MAR when the patient goes for surgery?

A

MAR goes with them

37
Q

What happens to the pre-op orders after surgery?

A

They are discontinued. The physician will reorder if they are to be continued.

38
Q

What are the 9 steps for transcribing medication orders?

A
  1. Scan the order and fax to the Pharmacy if there are meds or IV’s with medications or KCl on the order.
  2. Notify RN of any STAT medication orders. Call Pharmacy to indicate order is coming and is STAT.
  3. Stamp “Faxed” on the order and indicate date & time.
  4. Find the MAR & Kardex (prn). CHECK and DOUBLE CHECK the patient’s name and then record the medication order.
  5. All large volume infusions containing medications, IV antibiotics (Abx), and KCl are recorded on the MAR.
  6. All medication orders are discontinued post-op. They must be re-ordered INDIVIDUALLY by the Physician. MAR will be in the chart when the patient returns from surgery.
  7. Symbolize the completed medication order with initials, status, and time
  8. Add blank addressographed Physician’s Orders prn.
  9. Flag the chart for the RN
39
Q

What are the guidelines for recording on the MAR?

A
  1. Transcribe medication orders in black pen onto a manual MAR after addressographing all pages, completing the date, noting allergies and indicating which pages are for routine or prn medications ORfind the existing MAR in the MAR binder. Check the name and date carefully to ensure you have the correct MAR. (Wrong entries on a MAR could have severe consequences for the patient).
  2. Check medications ordered to ensure patient has no allergies before transcribing (remember auto fail on exam PO if medications are transcribed)
  3. Regular scheduled medications, STATS, & one-time doses are recorded under the Routine medications section of a computerized MAR OR written in one of the spaces on the manual MAR. Include the name of the medication, dosage, route, and frequency. Enter the times the medication is to be administered (except STATS) under the 24-hour clock if this is the policy of the Nursing Unit.
  4. PRN medications are to be transcribed to the PRN page of the computerized or manual MAR. Include name of medication, dosage, route, and frequency. There are no administration times for prn meds.
  5. If a medication is reordered with no break in administration, and no change in drug order, enter R/O beside the medication.
  6. If a Physician orders “continue medication”, then write continue on the MAR beside the designated medication.
  7. If a medication is to be held for diagnostic tests or procedures, enter the date and time of dose to be held in PENCIL so that it may be erased when the medication is resumed.
  8. If a medication is discontinued, write D/C beside medication with initials & time and cross out any future times that the medication was to be given.
  9. If a medication is changed, write changed beside medication with initials & time and cross out any future times and rewrite the medication reflecting the changes.
  10. Check and double check the patient’s name and the medication that you have recorded to ensure you have completed it accurately.
40
Q

When should you advise the RN about information on the PO?

A
  • When the order is STAT / NOW / IV Push / IV Bolus
  • When the administration time of a medication is within 20 minutes after the order has been written.
  • When the administration time of a medication is within 1 hour before the order has been written.
  • When it is more than 8 hours until the next administration time (except daily HS)
  • When a new IV/ or SL set-up is required (also, meds given by IV where no initial IV set has been noted)
  • When an IV has been discontinued
  • When a medication has been ordered to which the patient is allergic
  • When a med is ordered routine and it has already been ordered prn (or vice versa). Need to clarify with RN if both orders stand or if the pre-existing order is cancelled.
41
Q

What are the steps for transcribing Doctors Orders?

A
  1. Scan the Physician’s order for new orders and check the previous orders
  2. Fax to Pharmacy if medications ordered and stamp with fax stamp & record date & time – call to advise if any STAT’s & symbolize department aware PO – red ink
  3. Advise RN & symbolize PO if any of the following:
  • When the order is STAT / NOW / IV Push / IV Bolus
  • When the administration time of a medication is within 20 minutes after the order has been written.
  • When the administration time of a medication is within 1 hour before the order has been written.
  • When it is more than 8 hours until the next administration time (except daily HS)
  • When a new IV/ or SL set-up is required (also, meds given by IV where no initial IV set has been noted)
  • When an IV has been discontinued
  • When a medication has been ordered to which the patient is allergic
  • When a med is ordered routine and it has already been ordered prn (or vice versa). Need to clarify with RN if both orders stand or if the pre-existing order is cancelled.
    1. Check & double checks patients name carefully to ensure you have the correct MAR/K (Wrong entries on a MAR/K could have severe consequences for the patient).
      1. Transcribe medication orders in black pen onto a manual/computer MAR after addressographing all pages, completing the date, noting allergies and indicating which pages are for routine or prn medications OR find the existing MAR in the MAR binder.
  • Regular scheduled medications, STATS, & one-time doses are recorded under the Routine medications section of a computerized MAR or written in one of the spaces on the manual MAR. Include the name of the medication, dosage, route, and frequency. Enter the times the medication is to be administered (except STATS) under the 24-hour clock if this is the policy of the Nursing Unit.
  • PRN medications are to be transcribed to the PRN page of the computerized or manual MAR. Include name of medication, dosage, route, and frequency. There are no administration times for prn meds.
  • If a medication is reordered with no break in administration, and no change in drug order, enter R/O beside the medication.
  • If a Physician orders “continue medication”, then write continue on the MAR beside the designated medication.
  • If a medication is to be held for diagnostic tests or procedures, enter the date and time of dose to be held in PENCIL so that it may be erased when the medication is resumed.
  • If a medication is discontinued, use a yellow highlighter to stroke out the medication plus any future times that the medication was to be given.
  • If a medication is changed, highlight out the entire order and future times and rewrite the medication reflecting the changes.
  1. Intravenous Orders:

• Discontinued IV Orders with or without medications erase from Kardex including saline flush record “D/C IV” on Kardex in intravenous section with date.highlight

  1. Transcribe orders onto the Kardex – in pencil
  2. Symbolize PO – black ink
  3. Check and double check to ensure orders are complete before signing off PO – Black ink
    with initials & status, date & time at bottom left hand corner of Physician’s Order
  4. Draw diagonal lines under order if near bottom of page/PO prn
  5. Stuff chart (blank Physician’s orders)
  6. Flag chart for RN
42
Q

Where are regularly scheduled medications, STATS and one-time doses recorded?

A

Under the Routine medications section of a computerized MAR or written in one of the spaces on the manual MAR

43
Q

Where are PRN medications transcribed?

A

To the PRN page of the computerized or manual MAR

44
Q

Are there administration times for prn meds?

A

No

45
Q

What symbol must you notate if a medication is reordered with no break in administration or change in drug order?

A

R/O

46
Q

What must you write on the MAR beside the designated medication if a physician orders “continue medication”?

A

Continue

47
Q

If medication is to be held for diagnostic tests or procedures, what is the procedure?

A

Enter the date and time of dose to be held in PENCIL so that it may be erased when the medication is resumed

48
Q

What happens if a medication is discontinued?

A

Using a yellow highlighter, stroke out the medication plus any future times that the medication was to be given

49
Q

What happens if a medication is changed?

A

Highlight out the entire order and future times, then rewrite the medication reflecting the changes

50
Q

What happens if an IV order (with or without medications) is discontinued?

A

Erase from the Kardex including saline flush record “D/C IV” on Kardex in intravenous section with date. Highlight.

NUC0520 NUC140 Medication Order Transcription (8 decks)

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