Writing Orders and Prescriptions

Educational Objectives

• The student will be able to write standard admission orders

• The student will be able to write correct medication orders

• The student will be able to write complete discharge orders

• The student will be able to write clear and legible prescriptions

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

ADC VANDALISM

• 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 12Coreg 6.25 mg q 12Lipitor 80 mg po dailyASA 325 mg po dailyLisinopril 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 SmithInternal Medicine ResidentPhone number: 070-777-8888

A Medication Order

• Always place the patients name, patient identification

number if one is available (hospital, service number etc.)

• 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

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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 attending

or licensed physicians

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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 ??

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