Writing Orders and Prescriptions
Educational Objectives
• The student will be able to write standard admission
orders
• The student will be able to write correct medication
orders
• The student will be able to write complete discharge
orders
• The student will be able to write clear and legible
prescriptions
Outline
• Admission Orders
• Medication Orders
• Discharge Orders
• Prescription Writing
Admission Orders
• All patients need a standard conventional set of
orders when they are admitted or transferred
between floors within the hospital
• Gives direction to nurses on patient care
• Useful phase to remember is:
– ADC VANDALISM or ADC VAAN DISML
ADC VANDALISM
• Admit to Internal Medicine service under Dr. ____
• Diagnosis: list in order of priority
• Condition: good, stable, fair, guarded, critical
• Vitals: every 4 hours, every shift, routine
• Allergies: List medication and food allergies
ADC VANDALISM
• Nursing: I/O’s, daily weight, neuro-check, seizure
precautions
• Diet: regular, low sodium, clear liquid, nothing per
oral (NPO), diabetic
• Activity: bed rest, up to chair, ambulate 3 times daily
• Labs/Imaging: CBC and chemistry every morning
ADC VANDALISM
• IV Fluids: Normal saline 100 cc/hr x 24 hrs
• Special request: example commode to bedside
• Medications: List the medications that you want
patient on for example antibiotics, DVT prophylaxis
• Always put parameters for the nurse to call you
– House officer calls: Notify house officer if BP > 150/100,
temperature > 101°F
Other Important Things for Admission
Orders
• Can also place on the admission orders:
– Consults: Consult specific specialty services (Cardiology)
– Code status: Full code, Do not resuscitate (Country specific)
• Write legible orders as others have to read them !
• You must sign your name, the service you are with and
your phone number (attending should co-sign in 24 hrs)
• Admit to: Internal Medicine Service under Dr. Siadi, resident Dr. ____
• Diagnosis: Congestive Heart Failure
• Condition: Stable
• Vitals: q 4 hours
• Allergies: Penicillin
• Nursing: Please record I/O’s, record daily weights, Fluid restrict to 1.5 liters per day
• Diet: Low sodium
• Activity: Out of bed as tolerated
• Labs: CBC, Chemistry panel, Chest X-ray now; Chemistry panel twice daily
• IV Fluids: None
• Medications:
Furosemide 40 mg IV q 12
Coreg 6.25 mg q 12
Lipitor 80 mg po daily
ASA 325 mg po daily
Lisinopril 20 mg po daily
• Instructions: Please call house officer if BP < 100/50 > 150/00, Temp > 101.4°F, RR <10
>20, HR <55 > 100
• Consult: Cardiology
Dr. John Smith
Internal Medicine Resident
Phone number: 070-777-8888
A Medication Order
• Always place the patients name, patient identification
number if one is available (hospital, service number etc.)
• Place weight of patient and allergies on the order sheet
• Drug name, strength, dose, route, frequency
– Lisinopril 20 mg po (by mouth) daily
• Sign your name, service and phone number
• Date and time your order
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Writing Proper Medication Orders
• Always, always write the drug name (generic), strength,
route, and frequency of use
• Most medications have an indefinite duration unless you
specify otherwise
– You need to write if a medication is as needed (PRN) and qualify the
order (Tylenol 650 mg po q 4 hrs as needed for pain or temp > 101.4°F
– Antibiotics need to have a duration of time associated with them
Writing Proper Medication Orders
• Changes to prior orders should be written on a new
order sheet
• Do not use trailing zeros (e.g. 1.0 mg)
• Always write preceding zeros (e.g. 0.1 mg)
• Always be specific with what you want done and if
any questions call the nurse or pharmacist
Discharge Orders - Sample Orders
• Discontinue: all lines and tubes
• Discharge home with: Instruction on what the patient leave
the hospital with for example the discharge narrative
• Discharge diagnosis: What was the final diagnosis?
• Condition: What is the patient’s condition at discharge?
• Activity: Describe what kind of activity they are able to do?
Discharge Orders - Sample Orders
• Diet: Make recommendations on diet such as low sodium
• Medications: List all the medications that you want the
patient to take
– Make sure the new medications are identified for the patient !!
• Follow-up: Specify whom you want the patient to follow-up
and when
• Instructions: Specify and special instructions for the patient
Abbreviations with Medication Orders
• PO= per oral, PR = per rectal, gtt = drops, IV =
Intravenous
• qd = once a day
– Abbreviation is no longer allowed on charts
– Should write out the word daily or qDay instead
• bid = twice a day
• tid = three times a day
• qid = four times a day
Abbreviations with Medication Orders
• q12 = every 12 hours (not the same as bid)
– q12 means midnight and noon
– Bid means you give the medication when the patient wakes up
and prior to bed
• qAM = every morning
• qHS = every evening
• qAC = before every meal
• prn = as needed
Medication Writing Examples
• Furosemide 40 mg po bid
• Ceftriaxone 1 gram IV q 12° x 14 doses – first dose
stat
• Prednisone 40 mg po daily x 2 days, then 20 mg po
daily x 2 days
• Maalox 30 ml q 4-6° prn dyspepsia
Prescription Writing
• Should be written on an appropriate prescription pad
• Controlled substances, including narcotics and
benzodiazepines should be prescribed by attending
or licensed physicians
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Prescription Writing Example
• Patient’s name:
Date:
• Drug Name: Lisinopril 20 mg
• Sig(Instructions): 1 tab by mouth daily
• Disp (dispense): # 90 (ninety) tabs
• Refills: 3
Any Questions ??
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