Writing Orders and Prescription Writing

Writing Orders and Prescription Writing Resident Orientation Course 2012 Presented by Dr. Siadi

Outline • Admission Orders • Medication Orders • Discharge Orders • Prescription Writing

Admission Orders • All patients need a standard conventional set of orders when they are admitted or transferred between floors within the hospital • Gives direction to nurses on patient care • Useful phase to remember is: • ADC VANDALISM or ADC VAAN DISML

ADCVANDALISM • Admit to Internal Medicine service under Dr. ____ • Diagnosis: list in order of priority • Condition: good, stable, fair, guarded, critical • Vitals: every 4 hours, every shift, routine • Allergies: List medication and food allergies

ADC VANDALISM • Nursing: I/O’s, daily weight, neuro-check, seizure precautions • Diet: regular, low sodium, clear liquid, nothing per oral (NPO), diabetic • Activity: bed rest, up to chair, ambulate 3 times daily • Labs/Imaging: CBC and chemistry every morning

ADC VANDALISM • IV Fluids: Normal saline 100 cc/hr x 24 hrs • Special request: example commode to bedside • Medications: List the medications that you want patient on for example antibiotics, DVT prophylaxis • Always put parameters for the nurse to call you • House officer calls: Notify house officer if BP > 150/100, temperature > 101°F

Other Important Things for Admission Orders • Can also place on the admission orders: • Consults: Consult specific specialty services (Cardiology) • Code status: Full code, Do not resuscitate (Country specific) • Write legible orders as others have to read them ! • You must sign your name, the service you are with and your phone number (attending should co-sign in 24 hrs)

Admit to: Internal Medicine Service under Dr. Siadi, resident Dr. ____ • Diagnosis: Congestive Heart Failure • Condition: Stable • Vitals: q 4 hours • Allergies: Penicillin • Nursing: Please record I/O’s, record daily weights, Fluid restrict to 1.5 liters per day • Diet: Low sodium • Activity: Out of bed as tolerated • Labs: CBC, Chemistry panel, Chest X-ray now; Chemistry panel twice daily • IV Fluids: None • Medications: • Furosemide 40 mg IV q 12 • Coreg 6.25 mg q 12 • Lipitor 80 mg po daily • ASA 325 mg po daily • Lisinopril 20 mg po daily • Instructions: Please call house officer if BP < 100/50 > 150/00, Temp > 101.4°F, RR <10 >20, HR <55 > 100 • Consult: Cardiology • Dr. John Smith • Internal Medicine Resident • Phone number: 070-777-8888

A Medication Order • Always place the patients name, patient identification number (SSN) • Place weight of patient and allergies on the order sheet • Drug name, strength, dose, route, frequency • Lisinopril 20 mg po (by mouth) daily • Sign your name, service and phone number • Date and time your order www.csuchico.edu

Writing Proper Medication Orders • Always, always write the drug name (generic), strength, route, and frequency of use • Most medications have an indefinite duration unless you specify otherwise • You need to write if a medication is as needed (PRN) and qualify the order (Tylenol 650 mg po q 4 hrs as needed for pain or temp > 101.4°F • Antibiotics need to have a duration of time associated with them

Writing Proper Medication Orders • Changes to prior orders should be written on a new order sheet • Do not use trailing zeros (e.g. 1.0 mg) • Always write preceding zeros (e.g. 0.1 mg) • Always be specific with what you want done and if any questions call the nurse or pharmacist

Discharge Orders - Sample Orders • Discontinue: all lines and tubes • Discharge home with: Instruction on what the patient leave the hospital with for example the discharge narrative • Discharge diagnosis: What was the final diagnosis? • Condition: What is the patient’s condition at discharge? • Activity: Describe what kind of activity they are able to do?

Discharge Orders - Sample Orders • Diet: Make recommendations on diet such as low sodium • Medications: List all the medications that you want the patient to take • Make sure the new medications are identified for the patient !! • Follow-up: Specify whom you want the patient to follow-up and when • Instructions: Specify and special instructions for the patient

Abbreviations with Medication Orders • PO= per oral, PR = per rectal, gtt = drops, IV = Intravenous • qd= once a day • Abbreviation is no longer allowed on charts • Should write out the word daily or qDay instead • bid = twice a day • tid= three times a day • qid = four times a day

Abbreviations with Medication Orders • q12= every 12 hours (not the same as bid) • q12 means midnight and noon • Bid means you give the medication when the patient wakes up and prior to bed • qAM= every morning • qHS = every evening • qAC = before every meal • prn= as needed

Medication Writing Examples • Furosemide 40 mg po bid • Ceftriaxone 1 gram IV q 12° x 14 doses – first dose stat • Prednisone 40 mg po daily x 2 days, then 20 mg po daily x 2 days • Maalox 30 ml q 4-6° prn dyspepsia

Prescription Writing • Should be written on an appropriate prescription pad • Controlled substances, including narcotics and benzodiazepines should be prescribed by licensed physicians www.essentialtremor.org

Prescription Writing Example • Patient’s name: Date: • Drug Name: Lisinopril 20 mg • Sig(Instructions): 1 tab by mouth daily • Disp (dispense): # 90 (ninety) tabs • Refills: 3

Any Questions ?? www.jeffkorhan.com

Writing Orders and Prescription Writing