Medication Transcription,
Verifying Medication Orders &
Administration
By:
Evelyn W. Stone RN.,BSN.,M.Ed.
www.qprofessionalmentalhealthservice.com
Types of Drug Orders
Written
Verbal
PRN
Discontinued
STAT
Written Order
 Prescriber may write order on order form.
 Prescriber may call order in to pharmacy.
 Carefully check medication label to be
sure it agrees with the order you have
received.
 FAXED orders are legal and acceptable.
Verbal Order
May be received in person or on the
phone (only by nurses or pharmacists).
The person receiving it must prepare a
written copy of the order for the
prescriber’s signature.
PRN Order
Medication/treatment may be used “as
needed”
Include what the medication is.
Include what the treatment is.
The problem being treated.
Frequency of administration.
Discontinue Order
 Medication/treatment is to be stopped
 Discontinued medications should be
immediately removed
 D/Cd meds can be 1. returned to the pharmacy
2. flushed down a drain
 Document name of med, amount, method and
date of disposal on med disposal form
STAT Orders
 Do it now
 Get the med and give to client
 Document in designated section on the MAR
 Report to oncoming nurse of the STAT order and
that it was carried out
STAT (Continued)
Use highlighter and yellow out the section
of the MAR where you initialed or signed
that the stat med was given.
Document in the progress notes that the
medication was given.
Physician Orders
All orders, whether written or verbal, must
include:
 Client name
 Medication to be given
 Strength of medication
 Dose to be given
 Frequency to be given
 Route
 Length of time to be given
Medical Alerts/Allergies
Physician must be made aware of…
1. Allergies
2. Conditions
3. All other meds client is taking
which might contraindicate a specific
medication.
***Be prepared to give complete, correct
information about a client’s diagnoses,
allergies, and all current meds to physician.
Factors that Influence Medication Dosage
Age
Weight
Time
Rate Excreted
Route
Drug Combinations/Interactions
Condition of the client
Age
Pediatric and the Elderly excrete meds at
different rates
Weight
Some medication dosages are calculated
by the physician & based on body weight.
Time
The time is specified if it is to be given
once a day.
If unsure of the time in which the med is to
be given, call the pharmacist.
Call the Administrator, Director or Qualified
Professional
Route
How medications are taken and
absorbed by the body may affect the
dosage.
Drug Combinations/Interactions
Two drugs given together may react
differently than the same drugs given
separately.
Condition of the Client
Behavior
Seizures
Diabetes
Vital Signs (history of high BP, fast
irregular heart rate)
Acceptance of food, fluids
Mobility
Others
Basic Rules for Administering Medications
Be sure medications are being taken as prescribed. Be
alert to changes in client’s behavior, and physical wellbeing. Report changes to the Administrator & Nurse.
 Correct transcription of orders
 Knowledge of drugs being given
 Special administration instructions
 Knowledge of client’s physical condition
 Knowledge of client’s emotional status
 Climate conducive to concentration
 Communication of information to others
 Resources for medication information
Correct Transcription of Orders
 Read every word on the script.
 Fax the script to the pharmacy.
 When the medication is received from the
pharmacy, check to make 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.
Knowledge of Drugs Being Given
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a.
b.
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Name of Medication and dosage
Why it was ordered
What benefit should be expected
Side-effects to be expected
Special monitoring needed:
Vital signs
Stool records c. seizure records
Special administration instructions:
1. crushed or chewed
2. given in food
3. need to be given on empty stomach
4. given with any liquid
Knowledge of Client’s physical condition
Medical alert – Seizures, Diabetes, HIV
etc.
Physical limitations – Spinabifeda,
amputee etc.
Knowledge of client’s emotional
status
Disoriented
Hostile
Mute, withdrawn
Refusing medications
Assaultive behavior
Climate Conducive to Concentration
Temperature 68-82 degrees
Not too hot
Not too cold
Communication of Information to Others
Drug Information
Learn the information that comes with the
drug.
Call the Pharmacist and request
medication leaflets that are suitable for lay
public.
Client information – Special alerts to staff.
Staff to give client education each time the
meds are given to help the client
recognize his meds and what they are for.
Resources for Medication Information
Pharmacist
Physician/Dentist
RN Consultant/RN Qualified Professional
Drug Information Sheet
Drug Handbook
Common Dosage Forms
Solids
Topical
Tablet
Capsule
Liquids
Gases
Solids
 Suppository- small, solid, cone shaped, glycerin base,
melt at body temperature, administered by rectum or
vagina.
Refrigerate as directed
 Topical- applied directly to skin, lotion (external use),
paste (mixture of powders and ointments), ointment,
cream (suspension of oil and water), powder (finely
ground drugs), shampoo (medication in soap), patches
(slowly release meds.), Aerosol sprays (suspended in
gas, e.g. Desenex spray, Cruex spray).
Used for local effect
Solids (cont.)
 Tablet- powdered drug compressed into
small, hard disc
 Capsule- powdered, liquid, or oil drug
form
1. hard or soft
2. dissolves quickly in the mouth
Liquids
Solution- one or more drugs dissolved in
water.
Suspension- preparation of a finely
divided, undissolved drug in a liquid.
Syrup- aqueous solution of sugar.
Elixir- drug mixed in an alcohol solution,
sweetened.
Gases
Inhalant- Medication carried into the
respiratory tract through air, oxygen, or
steam
Common Routes of Administering
Medications
Medications are designed for one or two specific
routes of administration. Physicians order the
route of administration when ordering the
medication.
 Oral
 Insertion
 Instillation
 Topical
 Inhalation
 Parenteral
Oral
1. By mouth
2. Buccal – between the cheek and gum
3. Sublingual – under the tongue
Insertion
“Putting in” vaginally or rectally
Instillation
Putting a drug in liquid or ointment form
into ears, eyes or nose
Topical
External application of meds to the skin,
nails or hair
Inhalation
Inhaling a drug into the respiratory tract.
Parenteral
By injection
** Injections are given by a licensed person.
A habilitation tech may be trained by a
licensed person to give insulin injection.
Correct Preparation and Administration
General Medication administration
procedures
Oral Medications
Liquid Medications
Inserting Medications
Instilling Medications
Topical Medications
 Inhalants
Nebulizers
General Med Administration Procedures:
Wash hands
Verify the order on the MAR by checking it
against the doctor’s order.
Do the “Three Checks”
a. when selecting from the storage
area
b. before pouring the med
c. after pouring and prior to returning
med to storage area
(continued)
Confirm the client’s identity.
Give the med by the route as ordered.
Document on MAR “IMMEDIATELY” after
they are given to each client before going
to the next client.
Never sign off meds prior to giving it.
** Complete this process for each client
prior to going to the next client.
Administering Oral Meds
 Pour the correct number of pills/capsules into
the medication lid, then into the med cup.
 Explain to client what meds you are giving and
the purpose at client’s level of understanding.
 Give with water or other fluid.
 Stay with client until all meds are swallowed.
 Sublingual meds are placed under the tongue.
Liquid Medications
 Liquid meds must be measured in a calibrated medication
cup.
 Place the med cup on a level surface at eye level
 Hold the med container so that the medication flows from
the side opposite the label so it doesn’t run down the
container and stain or obscure the label.
 Check the med cup again to make sure you have poured
the correct amount.
 For small amounts less than 5cc, use a calibrated syringe
to measure the medication.
 Give the med with the appropriate liquid.
 Always do the “3” checks before giving the med.
Eye Drops
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Explain purpose and procedure
Have client assume back-lying position
Put on gloves
Instruct client to look up toward ceiling
Hold dropper 1” above eye, install drops into pocket of
the outer 1/3 of the eye
Instruct client to close eye gently and wipe excess
away
Remove and discard gloves
Gather and dispose of equipment
Wash hands
Eye Ointments
 Follow steps for eye drops
•
•
Discard first bead of ointment
Squeeze small amount of ointment into
the lower eyelid from the side near the
nose to the outer eye
Ear Drops
 Draw proper amount of med into dropper
 Explain purpose of the med
 Put on gloves
 Straighten ear canal – adult pull up & back/child
pull down & back
 Hold the tip of the ear dropper just over the ear
canal.
 Client should remain on side for 5-10 minutes
 Remove gloves & wash hands
Nose Drops
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Explain purpose of med
Put on gloves
Have client lie on back with head slightly hyper-extended
Draw up med into dropper
Push up the tip of the client’s nose slightly
Hold dropper just above the nostril and direct its tip
toward the midline of the nose so the drops flow toward
the back of the nasal cavity.
Instill the number of drops
Have client remain in lying position for 5 minutes and
breathe through the mouth
Remove the gloves
Wash your hands
Topical
 Explain purpose of med
 Put on gloves
 Open container and place cap or lid upside
down to prevent contamination
 Use a tongue blade, gauze or cotton applicator
to apply
 Cover the end of the tongue blade, gauze or
applicator with med
 Apply medication to affected area
 Remove the gloves
 Wash your hands
Aerosol Sprays
Explain purpose of medication
Shake the container if indicated
Hold the container 6-12 inches from the
affected area
Spray evenly
Inhalants
 Explain the purpose of procedure
 Shake the inhaler
 Have client exhale completely then place the mouth
piece in mouth, close lips around it.
 Have client inhale slowly & deeply
 Repeat the procedure as necessary to give as
prescribed
 Client may gargle to remove medication from the mouth
 Clean mouth piece
 Return to storage place
Narcotics – Schedule II Drugs
 Controlled substances
 Secured under “DOUBLE LOCK” system
 Sign out each dose each time a dose is given on
the medication sign out sheet that came with the
medication from the pharmacy
 Always confirm the correct count of all
narcotics when oncoming and off going.
Safety Rules
Right Client
Right Drug
Right Dose
Right Time
Right route
Right Documentation
(Continued)
No medication should ever be given
without a doctor’s order
Encourage client to take meds as
prescribed
Keep an MAR on each client
For Each medication, your MAR should
include drug name, the amount to be given
& how often the drug should be taken
(Continued)
 Medication should always be administered
within 1 hour of the time it is prescribed
 If a client refuse medication, try & find out why
 You can not force a client to take medication
 Write “R” in the block of the date it supposed to
be given & circle it
 Write on the back of the MAR in the designated
area about the refusal
(Continued)
Document in the progress note the refusal
and the reason
Inform the Administrator
Notify the physician
Notify the team
Conclusion
1. Remember to do the “three” checks
2. Remember If there are more than “three”
pills recheck the order before
administering
3. Remember “6” checks
4. Remember Client education must be
done each time medication is given
Other Services
Medication Administration
Seizure Management
Behavior Management
Client Abuse
Incidents
Ten Traits of a Professional
Boundaries
Other Services
Mental Illness
Bloodborne Pathogens
Autism
Developmental Disabilities
Develop Procedure & Policy Manual
To Contact Instructor:
www.ewsastaffingnetwork.com
www.qprofessionalmentalhealtservice.com
1008-F Big Oak Court
Knightdale, NC 27545
(919) 266-7050