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Accepted Practice

Medication orders and abbreviations

A medication order is required for all medications administered in a healthcare facility. Every order must include the patient’s name, date, name of the drug, dose, route, frequency of administration, any special instructions, and the signature of the prescribing person. When medication orders are written and transcribed, abbreviations are often used. Most facilities have an approved list of abbreviations. Familiarize yourself with this list and use only those abbreviations. The Joint Commission has prepared a “do not use” list of abbreviations, while the Institute for Safe Medication Practices has prepared a list of error-prone abbreviations. Using any of these abbreviations can increase your risk for medication errors.

Medication orders are often based on frequency or urgency. You’ll see standing or routine orders for medications given on a regular basis until a patient is discharged or the order is otherwise cancelled. As-needed orders, called PRN orders, are for medications administered only when needed or requested. An example is

Orders for medications given prior to surgery or a procedure are considered one-time-only orders. An example is

A stat order means that you must give the prescribed drug immediately. Most facilities have policies in place indicating what “immediately” means. You’ll see this type of order when a provider prescribes a new drug for a patient or one to address a specific problem.

Medication orders can be written, verbal, or given by telephone. Traditionally, written medication orders are probably the most common. However, with computerized charting, physician-order entry programs allow providers with prescriptive authority to enter medication orders electronically. When orders are handwritten, a nurse or, in some cases, a unit clerk transfers the order to the patient’s medication administration record (MAR). It is your responsibility to check and initial all transcribed orders for your patients for accuracy and for legibility. If a medication order seems incorrect, inappropriate, or incomplete, contact the person prescribing the medication before you administer it.

You’ll receive verbal orders in the presence of a prescribing physician or other provider with prescriptive authority. This is most likely in an emergency situation when it is more important to give the drug immediately than to take the time to write it down first. Repeat the order back to the prescribing person for accuracy; this is a Joint Commission requirement. Once the patient is stable, transcribe the verbal order onto the appropriate form and make sure the prescriber signs it within 24 hours, or as your facility’s policy mandates.

 

You are likely to receive telephone orders when you update a provider about a change in a patient’s condition. When taking an order over the phone, make sure you read it back to the prescribing person to ensure accuracy. Again, be sure the prescriber signs it within 24 hours or as per your facility’s policy.