VERBAL ORDERS

Oral (verbal) and telephone orders should only be accepted in emergencies. The book titled Medication Errors (Cohen, 2007) cites reasons for possible errors in verbal orders:

Cohen also points out that errors can occur when verbal orders (spoken) are incomplete and the nurse assumes the prescriber’s intention. Recognizing the errors that can occur with verbal orders and wanting to decrease the potential errors when an oral or telephone order is taken, The Joint Commission requires that only “designated qualified staff” may accept verbal or telephone orders. The Joint Commission (2007) requires that the authorized individual receiving a verbal or telephone order first write it down in the patient’s chart or enter it into the computer, then read it back to the prescriber, and then receive confirmation from the prescriber who gave the order that it is correct. For the nurse to only repeat back the order is not sufficient to prevent errors and is not allowed by The Joint Commission. Any questions or concerns relating to the order should be clarified with the prescriber during the conversation. A verbal order must contain the same elements as a written order: the date of the order, name and dosage of the medication, route, frequency, any special instructions, and the name of the individual giving the order.

It must be noted that it was an oral or telephone order, and the signature of the nurse taking the order is required. Many institutions require that the order must be signed by the prescriber within 24 hours. Some institutions may require that medication orders written by a person other than a physician be countersigned by designated personnel.

The only time in which just a “repeat back” is acceptable to The Joint Commission is in situations where a formal “read back” is not feasible, for example, emergency situations such as a code or in the OR (operating room).

The medication order indicates the drug treatment plan or medication the health care provider has ordered for a client. Depending on the institution, the medication order may be written on a sheet labeled “physician’s order sheet” or “order sheet.” After the medication order has been written, the nurse or in some institutions a trained unit clerk transcribes the order. This means the order is written on the medication administration record (MAR). In an instance in which the nurse does not transcribe the order, the nurse is accountable for what is written and for verifying the order, initialing it, and checking it before administering.

At some institutions computers are used for processing medication orders. Medication orders are either electronically transmitted or manually entered directly into the computer from an order form. The use of the computer allows immediate transmission of the order to the pharmacy. The computerized medication record can be seen directly on the computer screen or on a printed copy. Medication orders done by computer entry allow the prescriber to make changes if indicated, and the orders are signed by the prescriber with an assigned electronic code. Once the medication is received on the unit, the medication order is implemented and the client receives the medication.

Computerized physician order entry (CPOE), according to Cohen (2007), “could prevent many problems that occur with written orders as well as clearly communicating medication orders, and avoiding dosing mistakes; it would also help in preventing serious drug interactions and monitoring and documenting adverse events and therapeutic outcomes.” In addition, the authors of the 2006 Institute of Medicine (IOM) report Preventing Medication Errors call for all health care providers to have plans in place for CPOE by 2008. By 2010, IOM recommends that all prescribers be using electronic prescribing and all pharmacies be capable of accepting electronic prescriptions (Cohen, 2007).

In some institutions fax (facsimile) transmission may be used to avoid telephone orders. Faxed orders, however, may not be clearly legible and can also cause errors in interpretation. Cohen (2007) recommends that faxed orders be reviewed carefully and that the pharmacy verify the order before dispensing the medication or wait for the original.

Despite the advent of technology many institutions still have handwritten orders and nurses must be familiar with transcription of orders.

Before transcribing an order or preparing a dosage, the nurse must be familiar with reading and interpreting an order. To interpret a medication order, the nurse must know the components of a medication order and the standard abbreviations and symbols used in writing a medication order as well as those abbreviations and symbols that should not be used. The nurse therefore must memorize the abbreviations and symbols commonly used in medication orders. The abbreviations include units of measure, route, and frequency for the medication ordered. The common abbreviations and symbols used in medication administration are listed in Tables 11-1 and 11-2 and must be committed to memory. The Joint Commission’s “Do Not Use” List is shown in Table 11-3, and ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations will be presented later in this chapter.

TABLE 11-2

Commonly Used Medication Abbreviations

Abbreviation	Meaning
a	before
aa, aa	of each
a.c., ac	before meals
ad lib.	as desired, freely
am, am	morning before noon
amp	ampule
aq	aqueous, water
b.i.d., bid	twice a day
b.i.w.	twice a week
	with
c, C	cup
cap, caps	capsule
CD	controlled dose
CR	controlled release
dil.	dilute
DS	double strength
EC	enteric coated
elix.	elixir
fl, fld.	fluid
GT	gastrostomy tube
gtt	drop
h, hr	hour
ID	intradermal
IM	intramuscular
IV	intravenous
IVPB	intravenous piggyback
IVSS	intravenous Soluset
KVO	keep vein open (a very slow infusion rate)
LA	long acting
LOS	length of stay
min	minute
mix	mixture
NAS	intranasal
NG, NGT	nasogastric tube
noc, noct	at night
n.p.o., NPO	nothing by mouth
NS, N/S	normal saline
	after
p.c., pc	after meals
per	through or by
pm, PM	evening, before midnight
p.o.	by mouth, oral
p.r.	by rectum
p.r.n., prn	when necessary/required, as needed
q.	every
q.a.m.	every morning
q.h., qh	every hour
q2h, q4h, q6h, q8h, q12h	every 2 hours, every 4 hours, every 6 hours, every 8 hours, every 12 hours
q.i.d., qid	four times a day
q.s.	a sufficient amount/as much as needed
rect	rectum
	without
sl, SL	sublingual
sol, soln	solution
s.o.s., SOS	may be repeated once if necessary
SR	sustained release
S&S	swish and swallow
stat, STAT	immediately, at once
subcut	subcutaneous
supp	suppository
susp	suspension
syp, syr	syrup
tab	tablet
t.i.d., tid	three times a day
tr., tinct	tincture
ung., oint	ointment
vag, v	vaginally
XL	long acting
XR	extended release

Note: Abbreviations identified as “do not use” by TJC have been removed from the abbreviation list, as have dangerous abbreviations identified by the ISMP.

In writing medication orders, some health care providers may use capital letters, and others may use lowercase letters; some may place a period after an abbreviation or symbol, but others do not. These variations often reflect writing styles.

WRITING A MEDICATION ORDER

The health care provider writes a medication order on a form called the physician’s order sheet. Order sheets vary from institution to institution. The order sheet should have the client’s name on it. A prescription blank is used to write medication orders for clients who are being discharged from the hospital or are seeing the doctor in an outpatient facility. Nurses often have to explain these orders to clients so they understand the dosages and other relevant information relating to their medications to ensure safety.

COMPONENTS OF A MEDICATION ORDER

When a medication order is written, it must contain the following seven important parts or it is considered invalid or incomplete: (1) client’s full name, (2) date and time the order was written, (3) name of the medication, (4) dosage of the medication, (5) route of administration, (6) frequency of administration, and (7) signature of the person writing the order. These parts of the medication order are discussed in detail in the following sections.

CLIENT’S FULL NAME

Using the client’s full name helps to prevent confusion of one client with another, thereby preventing administration of the wrong medication to a client. Many institutions use a nameplate to imprint the client’s name and record number on the order sheet; in addition there is usually a place to indicate allergies. In institutions that use computers, the computer screen may also show identifying information for the client, such as age and known drug allergies.

DATE AND TIME THE ORDER WAS WRITTEN

The date and time of the order include the month, day, year, and the time the order was written. This will help in determining the start and stop of the medication order. In many institutions the health care provider (or person legally authorized to write a medication order) is required to include the length of time the medication is to be given (e.g., 7 days); or he or she may use the abbreviation LOS (length of stay), which means the client is to receive the medication during the entire stay in the hospital. Even when not written as part of the order, LOS is implied unless stated otherwise. The policy regarding indicating the length of time a medication is to be given varies from institution to institution. At some institutions, if there are no specified dosages or days for particular medications, it is assumed to be continued until otherwise stopped by the health care provider or a protocol in place for certain medications, such as controlled substances (narcotics). Some medications have automatic stop times according to the facility (e.g., narcotics, certain antibiotics).

NOTE

A record of the time the order was written is preferred in many institutions, but omission does not invalidate the order. This same information is required in computer entry of medication orders.

NAME OF THE MEDICATION

The medication may be ordered by the generic or brand name (Figures 11-1 and 11-2). To avoid confusion with another medication, the name of the medication should be written clearly and spelled correctly.

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