References:
- Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition, ISBN 9780135428733, by Audrey Berman, Shirlee J. Snyder, and Geralyn Frandsen (Ch. 35, pp. 844–847)
A physician usually determines the client’s medication needs and orders medications, although in some settings nurse practitioners and physician assistants (PAs) can now order drugs (based on the country/state, and agency). Usually the order is written, although telephone and verbal orders are acceptable in some agencies.
Communicating a Medication Order
A drug order is written on the client’s chart by a primary care provider or by a nurse receiving a telephone or verbal order from a primary care provider. Most acute care agencies have a specified time frame (e.g., 24 or 48 hours) in which the primary care provider issuing the telephone or verbal order must cosign the order written by the nurse.
Types of Medication Orders
- A stat order indicates that the medication is to be given immediately and only once (e.g., morphine sulfate 10 milligrams IV stat).
- The single order or one-time order is for medication to be given once at a specified time (e.g., Seconal 100 milligrams at bedtime before surgery).
- The standing order may or may not have a termination date. A standing order may be carried out indefinitely (e.g., multiple vitamins daily) until an order is written to cancel it, or it may be carried out for a specified number of days (e.g., KCl twice daily * 2 days). In some agencies, standing orders are automatically canceled after a specified number of days and must be reordered.
- A prn order, or as-needed order, permits the nurse to give a medication when, in the nurse’s judgment, the client requires it (e.g., Amphojel 15 mL prn). The nurse must use good judgment about when the medication is needed and when it can be safely administered.
Do-not-use Abbreviations (JCI & ISMP Guidelines)
The following is a list of unacceptable abbreviations as outlined by The Joint Commission and Institute for Safe Medication Practices (ISMP), as adapted by Kozier & Erb. A more recent and comprehensive resource on these abbreviations can be found here.
| Abbreviation | Potential Problem | Use instead |
|---|---|---|
| U, u (unit) | Mistaken for “0” (zero), the number “4” (four), or “cc” | Write “unit” |
| IU (international unit) | Mistaken for IV (intravenous) or the number 10 (ten) | Write “International Unit” |
| Q.D., QD, q.d., qd (daily) | Mistaken for each other | Write “daily” |
| Q.O.D., QOD, q.o.d., qod (every other day) | Period after the Q mistaken for “I” and the “O” mistaken for “I” | Write “every other day” |
| Trailing zero (X.0 mg) | Decimal point is missed | Write X mg |
| Lack of leading zero (.X mg) | Decimal point is missed | Write 0.X mg |
| MS | Can mean morphine sulfate or magnesium sulfate Confused for one another | Write “morphine sulfate” |
| MSO4 and MgSO4 | Can mean morphine sulfate or magnesium sulfate Confused for one another | Write “magnesium sulfate” |
| > (greater than) < (less than) | Opposite of intended; mistakenly use incorrect symbol | Write “more than” Write “less than” |
| @ | Mistaken for the number “2” (two) | Write “at” |
| Cc | Mistaken for U (units) when poorly written | Write “mL” or “milliliters” |
| µg | Mistaken for mg (milligrams) resulting in one thousand-fold overdose | Write “mcg” or “micrograms” |
| TIW (three times a week) | Has been misinterpreted as “two times a week” or “three times a day” resulting in misdosing | Write “three times weekly” |
| AS (left ear) AD (right ear) AU (both ears) OD (right eye) OS (left eye) OU (each eye) | Mistaken for OS (left eye), OD (either “overdose” or “optic density”), and OU (“each eye” or “both eyes”) Mistaken as AD, AS, AU (right ear, left ear, each ear) | Write “left ear,” “right ear,” or “both ears,” as appropriate Use “right eye,” “left eye,” or “each eye” |
| HS | Has been used to indicate “half strength” and “bedtime” or “hour of sleep” | Write out “half strength” or “at bedtime,” as appropriate |
| SC, SQ, sub q (subcutaneous) | SC mistaken as “SL” (sublingual); SQ mistaken as “5 every”; the “q” in “sub q” has been mistaken as “every” | Write “subcut” or “subcutaneously” |
| Apothecary units | Unfamiliar to many practitioners Confused with metric units | Use metric units |
| Abbreviations for drug names | Misinterpreted due to similar abbreviations for multiple drugs | Write drug names in full |
Essential Parts of a Medication Order
- Full name of the client: the first and last names and middle initials or names, should always be used to avoid confusion between two clients who may have the same last name. In some cases, a patient identification number and primary care provider’s name are also placed on the order as further identification.
- Date and time the order is written: the day, month, and year is written. Some may also add on the time of day to eliminate errors when the nursing shifts change and makes clear when certain orders automatically terminate. For example, in some settings opioids can be ordered only for 48 hours after surgery. Therefore, a drug that is ordered at 1600 hours November 1, 2025, is automatically canceled at 1600 hours November 3, 2025. Many health agencies use the 24-hour clock, which eliminates confusion between morning and afternoon times. The 24-hour clock starts at midnight, which is 0000 hours.
- Name of the drug to be administered: clearly written, unabbreviated. Some settings only permit generic names, but trade names are still widely used.
- Dosage of the drug and Frequency of administration: the amount, the times or frequency of administration, and in many instances the strength; for example, tetracycline 250 mg (amount) four times a day (frequency); potassium chloride 10% (strength) 5 mL (amount) three times a day with meals (time and frequency). It is strongly recommended that dosages be written in the metric system for safety reasons.
- Route of administration: this part of the order, like other parts, is frequently abbreviated. It is not unusual for a drug to have several possible routes of administration; therefore, it is important that the route be included in the order.
- Signature of the individual writing the order—the physician if written, and the nurse if receiving a verbal or telephone order—makes the drug order a legal request. An unsigned order has no validity, and the ordering healthcare provider needs to be notified if the order is unsigned.
Prescriptions
When a primary care provider writes a prescription for a client, the prescription also includes information for the pharmacist. Therefore, a prescription’s contents differs from that of a medication order in a hospital.
- Descriptive information about the client: name, address, and sometimes age
- Date on which the prescription was written
- The Rx symbol, meaning “take thou”
- Medication name, dosage, and strength
- Route of administration
- Dispensing instructions for the pharmacist, for example, “Dispense 30 capsules”
- Directions for administration to be given to the client, for example, “take on an empty stomach”
- Refill and special labeling, for example, “Refill × 1”
- Prescriber’s signature
Communicating a Medication Order
- A drug order is written on the client’s chart by a primary care provider or by a nurse receiving a telephone or verbal order from a primary care provider. Most acute care agencies have a specified time frame (e.g., 24 or 48 hours) in which the primary care provider issuing the telephone or verbal order must cosign the order written by the nurse.
- The nurse or clerk then copies the medication order to a Kardex or medication administration record (MAR).
- MARs vary in form, but all include the client’s name, drug name and dose; and times and method of administration. In some agencies, the date the order was prescribed and the date the order expires are also included.
Computer Printouts
Increasingly, nurses receive computer printouts of a client’s medications instead of a copy of the primary care provider’s order. This method avoids errors and saves nursing time.
The nurse should always question the primary care provider about any order that is ambiguous, unusual (e.g., an abnormally high dosage of a medication), or contraindicated by the client’s condition. When the nurse judges a primary care provider–ordered medication inappropriate, the following actions are required:
- Contact the primary care provider and discuss the rationale for believing the medication or dosage to be inappropriate.
- Document in notes the following: when the primary care provider was notified, what was conveyed to the primary care provider, and how the primary care provider responded.
- If the primary care provider cannot be reached, document all attempts to contact the primary care provider and the reason for withholding the medication.
- If someone else gives the medication, document data about the client’s condition before and after the medication.
- If an incident report is indicated, clearly document factual information—not assumptions.