WRITING MEDICAL ORDERS, TRANSCRIBING MEDICATION

STATEMENT: This policy is formulated for all health care providers about writing and transcribing medical orders and for recording medication administration in the medical record

DEFINITION: A Medical Order - An authoritative direction or instruction, issued by a Physician, in writing, or by dictation, verbally or by phone, or otherwise, a rule or a course of action to be implemented by other health care providers, patient, family, legal guardians, or significant others, in the treatment, plan of care or service, for the patient. This may include prescription of medications, diagnostic tests, etc. Transcribing Medical Orders - To copy, write over again, transfer or translate information from the Physicians medical order or instructions on to the patients medical records for further medical or nursing action, e.g., issuing of the medication by Pharmacy Department, and administration of the medication to the patient. POLICY: All medical orders shall be written on a physician order sheet. These include but are not limited to diagnostic, therapeutic and palliative treatment as well as referrals to other disciplines and healthcare facilities, and orders for medications. Medication orders shall be written on the Physician Prescription Sheet. Orders shall be accurately transcribed by qualified health care providers. Medications administered by qualified health care providers shall be written on the designated forms, including the date, time, signatures and stamp.

PROCEDURES: Writing Medical Orders: Only qualified Physicians should write medical orders

Only orders written on designated order sheets should be considered valid to be carried out by health care providers Two order sheets should be utilized for writing medical orders:

1. Physicians Prescription Sheet should be used for medications order only and should be completed only by a privileged Physician .1.1 The bottom duplicate copy (pink) should serve as the medication prescription that should be filled by the Pharmacy .2. Physician Order Sheet should be used for all orders other than medication orders, and should be completed only by privileged Physicians 3. Transcription of Medication Orders: 1. The Registered Nurse who transcribes the medication order should complete the following .1 .2 .3 .4 .5 .6 .7 Order date Medication Dosage and Frequency Route Time Commencement date, if applicable Discontinuation date, if applicable

.2 Any change in the medication dose, route or frequency should be written as a new prescription. These changes should then be transcribed as a new order. Order date should indicate the date when the new prescription is written. .3 Transcriptions of all medication orders should require a verification of the accuracy of the transcribed order by a second Registered Nurse and it should be documented on the Medication Administration Record. .4 a. Recording Medication Administration: The Medication Administration Record should be utilized in all inpatient units, Emergency Department (Short Stay Unit), Day Care Unit and Radiology Department for documenting medications administered by all routes. The Intensive Care and Intermediate Care Units should utilize the Intensive Care or Intermediate Care Flow Sheet for documenting the full details of medications administered by intravenous infusions. Procedural areas and the peri-operative areas should document medication administration on their respective Medication Administration Records or Flow Sheets.

b.

c.

All health care providers authorized to administer medications should document the medication administration on the designated administration recording form immediately after administration with date and time A second licensed staff should witness and document the medication administration on the medication administration for Narcotics and Controlled Substances and High Alert Medications.