TRANSCRIBING ORDERS Flashcards
It is making a written copy of the doctor’s order for proper implementation of clients care and treatment. Nurses are legally responsible for carrying out the orders of the doctor in-charge unless the orders would result in client’s harm
TRANSCRIBING ORDERS
It is a written medical regimen of patient, which includes medications , treatment, diagnostic and surgical procedures and health instructions given by any accredited physician during patient confinement.
TRANSCRIBING ORDERS
All doctor’s order must be written in
pen not in pencil.
Have all entries countersigned by the
Clinical Instructor
In case of error, draw
a single horizontal line on the error and write the correct word beside it.
Materials and forms needed
Patient’s Chart with Physician’s Order Sheet
Nursing Kardex 1 & 2
Medicine Cards / Flaggings (Assorted Colors)
Medicine Sheet
Prescription Pad
Request Slip (for other departments)
Various Forms / Sheet
Black and Red Pens
Ruler
Pencil with Eraser
YELLOW –
internal medicine
GREEN –
SURGERY / EENT
BLUE –
Ob and gyne
PINK –
PEDIA
“SIGNATURE OVER PRINTED NAME”
Charting
Prepared by:
Requested by:
Printed name and signature
Signature over printed name
Staff Nurse
Staff Nurse on Duty
“FULL SIGNATURE”
Nurses Signature
Countersigning doctors order
Medicine Cards
“INITIALS”
Medication Sheet
Nursing Kardex
Per physician in the prescription pad
BLACK INK
7 – 6:59 = 7am – 6:59 pm
RED INK
7 – 6:59 = 7pm – 6:59 am
AM Shift
(8am to 4pm)
PM Shift
(4pm to 12mn)
NOC Shift
12mn - 8am
BLUE CARD
Bladder Training
Charges of Medical Equipment / Devices Used
Serial Monitoring of Blood Extraction
Compression Stockings
24Hr Urine Collection
Weaning
Special Endorsement
Borrowed Items, Medical Certificate, Medical Abstract, Reminders, etc.
GREEN CARD
I.V.T.T. / Direct IV / Bolus ONLY
YELLOW CARD
Infusion / Drips ONLY
PINK CARD
Blood / Blood Components
Oxygen
Prescription
Date
Name
Age
Sex
Room number
Address
Generic Name
Brand Name
Dose
Quantity
Form
Doctors Name / Countersign
License and PTR if needed
Full name and Signature of the Folks / Patient
Standing Order
Given on a regular basis until the order is discontinued.
Make a medicine card and indicate the standard timing (OD, Q4Hrs etc.)
Written on a separate medicine sheet for intended for standing medication.
The timing or specific time is not written unless administered.
PRN Order
Given when needed or as requested only.
Make a medicine card but do not write standard timing.
Written on a standing medications sheet..
PRN Medication Cards are placed in the
Kardex.
Pre-procedure Order
Given before the procedure or operation as ordered.
Make a medicine card but do not write standard timing
Written on a STAT / SINGLE DOSE / PRE PROCEDURE medication sheet..
Pre-procedure Medication Cards are placed in the
Kardex.
STAT / Single Dose Order
Should be given immediately / given only on a specified time.
Make a medicine card and write the time given.
Written on a separate medicine sheet for STAT / SINGLE/ PRE-PROCEDURE.
DISCONTINUING MEDICATIONS:
- Card out present medicine card.
- In the medicine sheet, draw a red line from the last dose of the medication administered up to the second to the last column. On the last column, write “D/C” and the date discontinued below it.
- In the Nursing Kardex 2, place a red line on the medication to be discontinued and write “D/C” and the date discontinued on top of the red line.
CHANGING TIMING OF MEDICATIONS:
1 Card out present medicine card and make a new card indicating the time.
2 In the medicine sheet, draw a red line from the last dose of the medication administered up to the second to the last column. On the last column, write “Changed Timing” and the date of changed timing below it.
3 Make a new entry in the medicine sheet indicating the new timing and draw a black line from the entry until the date of changed timing.
4 In the Nursing Kardex 2, place a red line on the medication to be changed timing and write “Changed Timing” and the date of changed timing on top of the red line.
5 Make a new entry on the Nursing Kardex 2 and indicate the new timing.
SHIFTING / REVISION OF MEDICATIONS :
1 Card out present medicine card and make a new card.
2 In the medicine sheet, draw a red line from the last dose of the medication administered up to the second to the last column. On the last column, write “Revised / Shifted” and the date shifted / revised below it.
3 Make a new entry in the medicine sheet indicating the new timing and draw a black line from the entry until the date shifted / revised.
4 In the Nursing Kardex 2, place a red line on the medication to be shifted / revised and write “Revised / Shifted” and the date on top of the red line..
5 Make a new entry on the Nursing Kardex 2 and indicate the new timing.
Laboratories flow
TREATMENT CHART
NURSING KARDEX 1
ENCODE IN COMPUTER
LABORATORY REQUEST SLIP
Pulmonary
TREATMENT CHART
MEDICINE CARD
MEDICINE SHEET
NURSING KARDEX 2
PRESCRIPTION PAD
Diagnostic Exam flow
XRAY
ECG
ABG
TREATMENT CHART
NURSING KARDEX 1
XRAY REQUEST
ECG REQUEST
ABG REQUEST
*attach PAR
Diagnostic Exam
ULTRASOUND
2D ECHO
EEG
OTHER DIAGNOSTICS
TREATMENT CHART
NURSING KARDEX 1
DIAGNOSTIC EXAM
UTZ REQUEST
CARDIOVASCULAR REQUEST
EEG REQUEST
*attach PAR
BOOKING
CONSENT
DIETARY
TREATMENT CHART
NURSING KARDEX 1
REPORT TO DIETARY DEPARTMENT
SPECIAL ENDORSEMENTS
TREATMENT CHART
BLUE CARD
REFER IF NEEDED
NURSING PROCEDURES
Important Points
Check and Verify Doctor’s Order
Prescribe Materials
Countersign orders once orders are carried out.
Gather Equipment
Perform Hand Hygiene
Explain the procedure
Provide Privacy
Document
Refer
Vital signs monitoring
Carry out in Nursing Kardex 1
How to plot in the Graphic Sheet:
Place a dot in the line = even
Dot in the space = odd
Black ink: T, R, BP
Red ink: P
Vital signs monitoring
Use ____ for PULSE RATE and the Post-operative Day (P.O.D.).
Red Ink
Neuro vital signs monitoring
Carry out in
Kardex 1
The 1st Hospital Day is written on the
following day
Oxygen saturation monitoring
Transcribe in
Carry out in
White Card
Nursing Kardex 1
Abdominal status monitoring
Transcribe in
Carry out in
White Card
Nursing Kardex 1
Abdominal girth and weight monitoring
Transcribe in
Carry out in
White Card
Nursing Kardex 1
CBG Monitoring
Nurses Action:
Transcribe the order in the Medical Treatment Kardex 2
Make a white card
Prepare and fill up CBG monitoring sheet
