Transcribing doctor's order

Transcribing doctor’s order

RAHIMA MANGELEN, SALENDAB, BSN, RNNQMC

MEEQAT GENERAL HOSPITALMADINAH, AL – MUNAWARRAH, K.S.A.

OBJECTIVE: TO BE ABLE TO INTERPRET INTELLIGENTLY DOCTOR’S ORDER

SCOPE: this work instruction is to be done by the a nurse

Medical Order – an order (written or verbal) made by the physician pertaining care and management.

WORK INSTRUCTION: Transcribe medical order to nursing kardex Fills up medication sheet, appropriate forms for lab. Investigation and

diagnostic request

*Be sure that the 8 RIGHTS are there in the doctor’s order

1.RIGHT PATIENT2.RIGHT MEDICATION3.RIGHT DOSE4.RIGHT ROUTE5.RIGHT TIME6.RIGHT DOCUMENTATION7.RIGHT REASON8.RIGHT RESPONSE

CORRECT TRANSCRIPTION OF ORDER

1. Read every word on the script2. When the medicine is received from the

pharmacy, check to make it sure that it is the correct medication.

3. Write each word on the MAR that is on the medication label

4. Recheck your transcription word for word to make sure that it was transcribed correctly.

1. Never transcribe doctor’s order with erasure or tampered2. Always write legibly, neatly, and correctly3. New order must be written date and time of order4. Do not revise / rephrase what have been written in the doctor’s

order, rewrite completely what have written in the order.5. If in doubt, double check doctor’s order sheet / ask SOD / ask

transcribing physician6. Arrange your drug accordingly7. Signing the medication sheet as prompt as possible after

administrating / given a due medicine8. Do not sign medication sheet in advance, without administering

the drug yet, especially IVTT meds9. Always coordinate with the unit head nurse with regards to the

new orders; new drugs ordered.10.always counter check for any new order11.BE MINDFUL ALWAYS!!!!...

TELEPHONE ORDER

WRITE DOWN THE ENTIRE ORDER READ BACK WITNESS SIGN WITHIN 24 HOURS 

VERBAL ORDER

REPEAT BACK START THE ORDER SIGN AFTER SITUATION IS OVER

OR BEFORE PHYSICIAN LEAVE THE AREA