Health Care Provider’s Role

Question 1

Prescribers

Answer 1

Physicians, nurse practitioners, physician’s assistants prescribes
medications by writing an order on a form in a patient’s medical record, in
an order book, or on a legal prescription pad.

Abbreviations
Can cause errors; use caution
Know prohibited and error-prone abbreviations. (p. 2086).

Question 2

Orders

Answer 2

Written (hand or electronic)
Verbal
Telephone
Sometimes a health care provider orders a medication by telephone or
by talking to a nurse in person. An order for a medication or medical
treatment made over the telephone is called a telephone order. If the order is
given verbally to the nurse, it is called a verbal order. When a verbal or
telephone order is received, the nurse who took the order writes the
complete order or enters it into a computer, reads it back, and receives
confirmation from the health care provider to confirm accuracy. The nurse
indicates the time and the name of the health care provider who gave the
order, signs it, and follows agency policy to indicate that it was read back.
The health care provider countersigns the order later, usually within 24
hours after giving it.Nursing students
cannot take medication orders of any kind. They give newly ordered
medications only after a registered nurse has wri􀄴en and verified the
order.

Question 3

Guidelines for Telephone and Verbal Orders

Answer 3

• Only authorized staff receive and record telephone or verbal orders.
The health care agency identifies in writing the staff who are
authorized.
• Clearly identify patient’s name, room number, and diagnosis.
• Read back all orders to health care provider (TJC, 2020).
• Use clarification questions to avoid misunderstandings.
• Write “TO” (telephone order) or “VO” (verbal order), including date
and time, name of patient, and complete order; sign the name of the
health care provider and nurse.
• Follow agency policies; some agencies require documentation of the
“read-back” or require two nurses to review and sign telephone or
verbal orders.
• The health care provider co-signs the order within the time frame required by the agency (usually 24 hours; verify agency policy).