Transcribing Physician

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Transcribing Physicians Orders

• By
• Nancy Knight

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Physicians Orders

• Admission Orders these are the orders that come
  with the patient when they are admitted to the
  facility. These are usually the most lengthy and
  contain multiple types of orders
• Routine Orders these orders relate to routine
  activities for the patient, such as diet,
  activity, routine medication changes or
  diagnostic testing
• Stat Orders these are orders the physician
  wants put into action immediately

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Prioritizing Orders

• Read all the orders when received
• Stat orders must always be taken care of
  immediately.
• Scan the list of orders to identify stat
  orders-take care of these immediately.
• Routine orders are not as urgent but remember
  that nothing happens for the patient until the
  order is transcribed.

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What is in an order?

• Name of test, medication, etc. that is needed
• Dose or amount if applicable
• Time to be done
• Method or mode of administration
• Other documentation
• Example CT scan of abdomen with oral contrast
  in AM

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What do I do with an order?

• Ask yourself
• Who all needs to know?
• How do I let them know?
• When should I let them know?
• What forms will be needed to document this event?

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Transcribing an Order

• Read through all orders.
• Prioritize orders by stat and routine.
• With routine orders, prioritize by when needed.

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Diagnostic Orders

• Orders for lab, x-ray or other diagnostic tests
  must be scheduled with the appropriate
  department.
• Facilities vary in whether this is done
  electronically or by phone.
• Must know what the tests are in order to schedule
  them with the appropriate department.
• Some tests need patient preparation prior to
  testing, you are responsible for seeing that this
  protocol is also put into action.
• For example a Fasting Blood Sugar requires that
  the patient be NPO after midnight. Instructions
  to Nursing services must also be given in
  addition to scheduling with the laboratory.

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Activity of Daily Living Orders

• ADL orders include special instructions in regard
  to diet, activity, elimination, etc.
• These are typically communicated to the Charge
  nurse and on the Nursing Care Plan.
• Special equipment needs should be communicated to
  Central Supply.
• Dietary orders need to be communicated to Dietary
  Services as well as to the nursing staff.

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Medication Orders

• Should include the Six Rights
• Right Medication
• Right dose or amount
• Right patient
• Right time
• Right method or mode of administration
• Right documentation

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Medication Orders

• Transmit order to the pharmacy
• Prepare medication administration instructions
  for Nursing staff
• Include medication instructions on routine
  Medication Administration Record if a routine
  med.
• If PRN or one time medication it is recorded in
  the nurses notes when given by the licensed
  nurse.

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Transcribing Physicians Orders

• Lets practice