Transcribing doctor's order

Lecture By:
RAHIMA MANGELEN, SALENDAB, BSN, RN
NQMC
MEEQAT GENERAL HOSPITAL
MADINAH, AL – MUNAWARRAH, K.S.A.

1. Transcribing doctor’s order RAHIMA MANGELEN, SALENDAB, BSN, RN NQMC MEEQAT GENERAL HOSPITAL MADINAH, AL – MUNAWARRAH, K.S.A.

2. 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

3. *Be sure that the 8 RIGHTS are there in the doctor’s order RIGHT PATIENT RIGHT MEDICATION RIGHT DOSE RIGHT ROUTE RIGHT TIME RIGHT DOCUMENTATION RIGHT REASON RIGHT RESPONSE

4. CORRECT TRANSCRIPTION OF ORDER Read every word on the script When the medicine is received from the pharmacy, check to make it sure that it is the correct medication. Write each word on the MAR that is on the medication label Recheck your transcription word for word to make sure that it was transcribed correctly.

5. Never transcribe doctor’s order with erasure or tampered Always write legibly, neatly, and correctly New order must be written date and time of order Do not revise / rephrase what have been written in the doctor’s order, rewrite completely what have written in the order. If in doubt, double check doctor’s order sheet / ask SOD / ask transcribing physician Arrange your drug accordingly Signing the medication sheet as prompt as possible after administrating / given a due medicine Do not sign medication sheet in advance, without administering the drug yet, especially IVTT meds Always coordinate with the unit head nurse with regards to the new orders; new drugs ordered. always counter check for any new order BE MINDFUL ALWAYS!!!!...

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

7. VERBAL ORDER REPEAT BACK START THE ORDER SIGN AFTER SITUATION IS OVER OR BEFORE PHYSICIAN LEAVE THE AREA