Types of Medication Orders

TYPES OF MEDICATION ORDERS Charold Baer, Bradley R. Williams, Clinical Pharmacology and Nursing, Springhouse Pub Co; 1991, pp. 90-94

Under the law, as outlined in the medical practice act of each country, licensed physicians as well as dentists, podiatrists, and in some countries optometrists may prescribe, dispense, and administer drugs. In selected circumstances, and within certain protocols, other health care professionals, such as nurses, pharmacists, or physicians’ assistants, legally may prescribe and dispense drugs. Nevertheless, physicians write the vast majority of medication orders. Usually, pharmacists dispense the drugs, and nurses administer them to patient. Requirements for medication orders A medication order may take one of two forms, depending on whether the prescriber is treating a hospitalized patient or an outpatient. For the hospitalized patient, the prescriber can order medications, along with all other orders such as those for diet, X-rays, and laboratory work, on the order sheet in the patient’s chart. The prescriber also can use a separate medication order sheet. For outpatients, the prescriber usually writes the medication order on a prescription pad sheet and gives it directly to the patient. The patient takes the medication order to a hospital or community pharmacy to be filled. The prescriber’s order sheet lists the patient’s full name for identification purposes. The order sheet may be stamped with complete identifying information, including the patient’s birth date, the hospital number, room number, and date of admission. Health care professionals must take extreme care in identifying patients, particularly if two or more patients with the same or similar names appear on the unit. The prescriber should give the generic or trade name of the drug and its dosage form, if more than one form of the drug is available. The prescriber should express the dose to be given at each administration in metric, apothecaries’, or household measures and should state the administration route. The most common administration routes are oral, intramuscular, subcutaneous, and intravenous, although additional routes involving other body structures and cavities exist. Oral medications, representing the majority, tend to be the safest, least expensive, and most convenient for the patient to take. The prescriber usually states the time schedule for administration as the number of times per day that the medication is to be administered. Upon noting the time schedule, the nurse then schedules the specific hours according to how quickly a supply of the medication can be procured, the medication’s characteristics, and institutional policies. The medication’s characteristics, including its nature and onset and duration of action, primarily determine the schedule. For instance, if regular, intermittent peak blood concentration levels of antibiotics must be maintained to combat infections, the prescriber will schedule the drug administration at regular intervals around the clock. The prescriber’s signature, along with the date and time of the day the order was written, also should appear. The date and time often are referred to when the order has an expiration date. After Rx, which means “take thou” (prescription, from Latin recipe), the prescriber writes the drug name, form, and dosage, along with instructions on the amount to be dispensed. After the abbreviation Sig., which means “let it be labeled”, the prescriber writes directions to the patient for taking the medication. The directions are followed by the prescriber’s signature, address, and telephone number. Finally, the prescriber indicates the number of times the prescription can be filled. Types of medication orders The following seven types of medication orders are routine in the hospital: standard written orders, single orders, stat orders, p.r.n. orders, standing orders, verbal (or oral) orders, and telephone orders.

Standard written orders apply indefinitely until the prescriber writes another order to alter or discontinue the first one. In some cases, the prescriber may specify on the standard written order a particular termination date. In many cases, hospitals establish policies that indicate how long orders for certain classes of drugs remain valid. Examples of drugs with controlled termination dates include narcotic orders for 3 days and antibiotic orders for 7 days. If the patient still needs the drug after the expiration date, the prescriber must rewrite the order. The prescriber must also rewrite standard written orders postoperatively if the medications are to be continued. Single orders are written for medications that are given only once. For example, a prescriber may order one tetanus toxoid injection for a patient with a laceration or puncture wound who received a primary tetanus toxoid series more than 10 years earlier. Calls for medications that are to be administered immediately for an urgent patient problem are known as stat orders. For instance, a prescriber may order a single dose of an antianxiety drug to calm an acutely agitated patient. P.R.N. orders derive their name from a Latin phrase (pro re nata) that means “as the occasion arises”. Prescribers write p.r.n. orders for medications that are to be given when needed. The administration time results from the collaborative judgements of the nurse and the patient. Sometimes a p.r.n. order delineates the reason for giving the drug. For example, the prescriber may write “Tylenol 650 mg P.O. p.r.n. for a temperature above 101.3 degrees F. (38.5 degrees C.).” If an ordered drug, such as acetaminophen (Tylenol), serves multiple purposes, some hospital policies state that the nurse administers the drug only for the specific condition mentioned in the order. Under such a policy, the nurse would not give Tylenol only for fever if the patient complained of a headache but had no fever. Other institutions allow the nurse to determine when to administer a p.r.n. drug. When administering a p.r.n. medication, the nurse should describe in the patient’s record the reason for its use and its degree of subsequent effectiveness. Also known as protocols, the standing orders establish guidelines for treating a particular disease or set of symptoms. These orders require considerable judgement and expertise in assessing the patient’s need for the medication and any dose-related adverse drug reactions that might occur. Special care areas of the hospital, such as the coronary care unit, routinely establish standing orders that apply to such drug therapies as morphine sulfate for chest pain and anxiety, lidocaine (Xylocaine) for ventricular tachycardia. Hospitals also may institute medication protocols that specifically designate drugs that a nurse may not give. Verbal orders Medication orders given orally rather than in writing are known as verbal orders. Health care professionals try to avoid using verbal orders because such orders can lead to miscommunication. In urgent situations, the nurse should write and sign the order dictated by the prescriber. Then the nurse should repeat the order aloud for the prescriber’s verification and request the prescriber to spell the drug name if necessary. The prescriber should sign the verbal order that the nurse has written as soon as possible. The institution should have a policy that dictates the time period in which the prescriber must sign a verbal order. If a patient experiences hypoglycemic or insulin shock and the prescriber instructs the nurse to prepare immediately 50 ml of 50% glucose for I.V. administration, the nurse should show the prescriber the label in the empty glucose vial while simultaneously stating the drug’s name and handing the syringe to the prescriber. Such actions allow the prescriber to confirm the accuracy of the drug and its dose. Telephone orders Verbal orders given to a nurse by a prescriber over the telephone may result in dangerous errors from mechanical problems involving the telephone and from the lack of nonverbal communication cues between the prescriber and nurse. Nurses should avoid telephone order; the nurse should ask another nurse to monitor the call on an extension telephone. By monitoring the call, the second nurse can confirm the order. Unfortunately, nurses cannot always include such monitoring on the clinical unit. Besides verifying the drug name given during a telephone order, the nurse should repeat orally the individual digits of the dose. The nurse then writes the order, indicating that it was a telephone order. Later, the prescriber must cosign the order within the time period established by institutional policy.