Transcribing Orders Checklists

Question 1

What are the 9 steps to transcribe a medication order?

Answer 1

1. Scan the order & fax to the pharmacy is 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 that it is STAT.
3. Stamp FAXED on the order and indicate time and date.
4. Find the MAR & Kardex. Check and double check the pt’s name & then record the med order.
5. All large volume infusions containing medication, IV antibiotics & KCl are recorded on the MAR.
6. All medication orders are D/C post-op.
7. Symbolize the completed medication order with initials, status, and time.
8. Add blank addressograph/labeled Physicians Orders prn.
9. Flag the chart for the RN

Question 2

What are the 8 steps to transcribe a saline lock order?

Answer 2

1. Scan the Physician’s Order and the previous order.
2. Check and double check the pt’s name
3. Record on the Kardex in the IV solution - date, saline lock & saline flush
4. Symbolize PO - K
5. Sign off
6. Draw diagonal lines prn
7. Stuff chart prn
8. Flag for RN

Question 3

When are you supposed to mark “DEPT AWARE”?

Answer 3

1. STAT medication orders (Pharmacy)
2. STAT blood work (Lab)
3. ABG’s (Lab)
4. Blood cultures (Lab)
5. Add on blood work (Lab)
6. When procedural trays are required; we need to order them from Sterile Processing Dept.
7. Any STAT orders where a department is called

Question 4

What is the 11 step process for discontinued IV orders - c and s medications?

Answer 4

1. Scan PO & previous order
2. Check and double check pt’s name
3. Notify RN of D/C IV order
4. Fax order to Pharmacy (when order includes meds or KCl)
5. Symbolize PO - RN Aware
6. If order is on Kardex:
   a) Erase from Kardex including saline flush
   b) Record “D/C IV” on Kardex in IV section with date
7. Symbolize PO - K
8. If order is on MAR:
   a) Highlight D/C’d order
   b) Symbolize PO - MAR
9. Sign off
10. Stuff prn
11. Flag for RN

Question 5

What is the 10 step process for routine medication transcription?

Answer 5

1. Scan PO and previous order.
2. Fax to pharmacy - fax stamp with date and time.
3. Record each medication order line by line from PO to the MAR (in black ink. NEVER use whiteout)
4. Check and double check pt’s name
5. Record each medication in a separate space with admin. times
6. Symbolize PO - MAR (black ink)
7. Sign off on PO when all orders transcribed (black ink) with initials, status and time
8. Draw diagonal lines under order if near bottom of page
9. Stuff chart prn
10. Flag for RN

Question 6

When are you supposed to symbolize APPT?

Answer 6

1. Booking appointments for clinics
2. Booking appointments for diagnostic tests and procedures
3. Booking follow up appointments upon D/C

Question 7

What is the 13 step process for transcribing PRN, One-Time and STAT medication orders?

Answer 7

1. Scan PO and previous order.
2. Fax order to Pharmacy - fax stamp with date adn time.
3. If there is a STAT - let the RN know.
   a) symbolize PO - RN Aware
   b) call pharmacy
   c) symbolize PO - Dept aware
4. Check and double check pt’s name
5. Record medication order line by line from PO to MAR
6. Record PRN med orders on a separate MAR from routine meds
7. Record ONE TIME, STAT med orders on the MAR with the routine meds
8. Record each med in a separate space with admin times for ONE TIME meds only.
9. Symbolize PO - MAR
10. Sign off PO when all orders transcribed with initials, status, and time
11. Draw diagonal lines under if near the bottom of the page
12. Stuff chart prn
13. Flag chart for RN

Question 8

When are you supposed to symbolize “RN Aware”?

Answer 8

1. When the order is STAT/NOW/IV Push/IV Bolus
2. When the admin time of a med is written within 20 mins after the order has been written
3. When the admin time of a medication is within 1 hour before the order has been written.
4. When it is more than 8 hours until the next administration time (except HS)
5. When a new IV set-up is required
6. When an IV has been D/C.
7. When a med has been ordered to which the pt is allergic.
8. 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.

** No RN aware for these orders - saline lock, IV -> SL, SL -> IV

Question 9

What are 11 things to remember when recording on the MAR?

Answer 9

1. Transcribe medication orders in black pen onto MAR after addressographing/labeling all pages, completing the date, noting allergies & indicating which pages are routine or PRN medications or find existing MAR in MAR binder. Check and double check name and date.
2. Regular scheduled meds, STATS & one-time doses are recorded under the Routine Med. section on MAR. Include name, dosage, route, and frequency. Enter the times the medications is to be administered, except STATS.
3. PRN meds are to be prescribed on the PRN page of MAR. Include name, dosage, route, and frequency. There are NO administration times for PRN meds.
4. If a med is recorded with no break in administration and no change in drug order, enter R/O beside med.
5. If a physician orders “continue med”, then write continue on the MAR beside the designated med.
6. If a med 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 med is resumed.
7. If a med is D/C, use yellow highlighter to stroke out the med plus any future times that the med was to be to given.
8. If a med is changed, highlight out the entire order and future times. Rewrite the med reflecting the changes.
9. Check and double check the pt’s name and the med that you have recorded to ensure you have completed it accurately.
10. Symbolize the orders
11. Stuff chart prn
12. Flag chart for RN