Exam V: Order Writing Flashcards
ABC DA VANDILISM
A = Admit to surgical service 6th floor B = Because- diagnosis/reason patient is being admitted C = Condition- good, fair, serious, critical
D = Diet- range of NPO to regular A = Activity- ranges from bedrest to ambulating
V = Vitals- frequency of vitals recorded A = Allergies and Adverse Reactions N = Nursing- checks and exams D = DVT Prophylaxis- especially if impaired mobility I = IVs- how much fluid and over what period of time L = Labs I = Inputs and outputs- monitoring hydration S = Special- imaging, consults, dressings, foley, etc. M = medications- name, dosage, frequency, and route
Components to Prescription Writing
- The reason for the medication
- Identification of the medication
- Instructions on how to take the medication
- Amount of medication to give
- Number of refills to give
- Your LEGIBLE name & Signature
- Date
Prescription: First Line
Drug Name
Forms - Tablets, capsules, redi-tabs, suspensions, ointments, creams, gels, lotions
Milligrams, milligrams/milliliter, concentrations
*Make sure you avoid mistakes by writing 0.5 instead of .5, or writing 5 and not 5.0
Prescription: Second Line
SIG: instructions on how to take it
Has 3 components
Amount - one, two, one tsp, 5 cc, one ounce, 30 cc, 2 gtts
Route - PO, PR, PV, SL, Transdermal, SQ, IM
Frequency - q 1 hour, q 8 hours, q 72 hours, qd, bid, tid, qid, qod, prn, until gone
Prescription: Third Line
Dispense
Amount: number, cc, vials
Put a line after number so it cannot be changed (Ex: 30 can’t be turned into 300)
May be better to write out amount (Ex: thirty)
Usually prescribed in 30 or 60 day supplies
Example: 1 tablet BID dosing would need 60 tablets
Refills
Also better to write out (Ex: one)
Write out “None”
New medications usually get very few refills to allow appropriate reevaluation
Chronic medications: up to 1 year of refills