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35-Transcribing Physician's Order

This document outlines the policy for transcribing physician's orders at Buraida Central Hospital. It states that all orders must be legible, clear, and complete. Nursing staff must transcribe orders exactly as written, including the date. They should not use unacceptable abbreviations and must document various types of orders like continuous IVs, one-time medications, and PRN orders in the appropriate sections of the medical administration record or kardex. The policy was prepared by the nurse supervisor, approved by several directors, and provides references and forms used.

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1K views4 pages

35-Transcribing Physician's Order

This document outlines the policy for transcribing physician's orders at Buraida Central Hospital. It states that all orders must be legible, clear, and complete. Nursing staff must transcribe orders exactly as written, including the date. They should not use unacceptable abbreviations and must document various types of orders like continuous IVs, one-time medications, and PRN orders in the appropriate sections of the medical administration record or kardex. The policy was prepared by the nurse supervisor, approved by several directors, and provides references and forms used.

Uploaded by

akositabon
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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BURAIDAH C ENTRAL H OSPITAL

Department : NURSING SERVICE Policy Index: PP-BCH-NR/GNR-035-IPP-E Title: TRANSCRIBING PHYSICIANS ORDER Applies to: All Nursing Staff Effective Date: 01-01-1432 H New

B. C. H.

IPP

Replace Number : XXXXX

Number of Pages: 2 Review Due: 01-12-1433 H

1. PURPOSE : 1.1To provide guidelines by which physicians orders are transcribed onto the Medical Adminis tation Record and Nursing Kardex.

2. DEFINITIONS: 2.1 N/A.

3. POLICY:

3.1 All Physician orders must be legible, clear and complete. 3.2 Overriding principles for transcription.
3.2.1 Transcribe the complete order as written. 3.2.2 Transcribe legibly. 3.2.3 Transcribe the date of the order. 3.2.4 Do not transcribe unacceptable abbreviations.

4. PROCEDURES : 4.1 Transcribe exactly how ordered.


4.2 Transcribe exactly as ordered. 4.3 For continuous IV medication transcribed to the continuous IV infusion section of the Medica tion Administration Record. This includes : Drug name, concentration (Total Dose in Volume) diluent type and rate. 4.4 For one time orders, transcribe and document administration on once only and pre - med drugs, ( stat dose ) of medication administration record. 4.5 For standardized administration time/schedule, follow standard medication time guidelines. The Registered Nurse may change standard medication times as appropriate.

Prepared by: Magdalena Venzuela Nurse Supervisor

Approved by : Abdulla Obeid Al-Harby Nursing Director

Page Number: 1/2

Approval Stamp

Form Index: BCH-QM-009-E

4.6 Medication Orders with specified times for administration are transcribed exactly as ordered and administered accordingly.

4.7 All medications ordered as PRN must be transcribed onto the PRN section of the Medication
Administration Record.

4.8 NGT feeding, O2 orders and all non-medication orders are transcribed to the Kardex.

5. FORMS AND EQUIPMENTS : 5.1 Doctor Order Sheet.


5.2 Kardex. 5.3 Medication Sheet.

6. REFERENCES : 6.1 www.clpna,com/portals/files/doc.

7. APPENDIX : 7.1 N/A. 8. APPROVAL:

Name Prepared by: Magdalena Venzuela 1.Abdulla Obeid Al-Harby Reviewed by: 2.Ehab El Husseiny Ibrahim 3.Manae Al-Belaihy Approved by: Ahmad Abdulla Al Omar

Position Nurse Supervisor Nursing Director QM Director Medical Director Nursing Director

Signature

Date
22-11-1431 H 24-11-1431 H 29-11-1431 H 29-11-1431 H 01-12-1431 H

Policy Number: PP-BCH-NR/GNR-035-IPP-E

Title: TRANSCRIBING PHYSICIANS ORDER

Page Number: 2/2

Approval Stamp

Form Index: BCH-QM-009-E

Policy Number:

Title:

Page Number: /N

Approval Stamp

Form Index: BCH-QM-009-E

Policy Number: PP-BCH-NR/GNR-035-IPP-E

Title: TRANSCRIBING PHYSICIANS ORDER

Page Number: 2/2

Approval Stamp

Form Index: BCH-QM-009-E

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