3.2 Medication Orders

A medication order—also referred to as a med order, medical order, or physician order—is a set of instructions given by a prescriber that specifies medications for an inpatient at a hospital or a resident of a long-term care facility. The prescriber who issues a medication order must have the appropriate credentials and privileges within that institution to relay the order to an on-site pharmacy. Because the hospital or inpatient facility that fills the order typically has the prescriber’s address and DEA number on file, this information is generally not required on a medication order.

Understanding Different Types of Medication Orders

Medication orders may be given verbally, written, or transmitted electronically. Written and electronic orders are generally preferred because there is a greater likelihood of medication errors when an order is given verbally. In many facilities, medication orders are entered directly into a computer by a prescriber. These orders communicate patient care directives to all members of the healthcare team. In addition to delivering instructions to the pharmacy, medication orders may provide directions for laboratory, radiology, dietary, physical therapy, and other departments within a healthcare facility. However, some smaller facilities continue to house medication orders within paper medical records.

There are several types of medication orders, including admission orders, daily orders, single orders, stat orders, prn orders, standing orders, and discharge orders. These orders are discussed below.

Admission Orders

An admission order is written by a physician upon patient admission to a hospital (see Figure 3.5). The order may be written in an emergency department or in a patient’s room. This type of medication order may contain drugs prescribed and taken before admission; suspected diagnoses; requests for laboratory tests or radiology examinations; instructions for the nursing staff; ordered medications, including the notation of drug allergies; activity instructions; and a patient’s dietary requirements.

Daily Orders

A daily order is an order for a medication to be administered regularly following the same instructions until the prescriber stops the order (see Figure 3.6). Typically, a physician or another healthcare professional examines a patient on a daily basis, but this frequency varies according to patient need. Critically ill patients may be examined several times a day. Patients may also be seen by numerous healthcare practitioners, according to their particular health issues. Every time a practitioner examines a patient, new orders, or changes to existing medication orders, may be written.

Single Orders

A single order is a one-time order that is administered at a specified time. For example, an order for medication to be given to a patient before surgery or another medical procedure is considered a single order.

Figure 3.5 Admission Order

A physician typically creates an admission order after examining a newly admitted patient.

Figure 3.6 Daily Order

A physician creates a daily order after each patient examination, when changing the order, or when submitting a new order.

Stat Orders

A stat order is an emergency order that is typically called in or sent electronically to a pharmacy. This type of order must receive priority attention and, consequently, must be immediately input into a pharmacy’s database and filled. After a final verification from a pharmacist, the medication is then sent to a patient care unit by a pharmacist or pharmacy technician for patient administration.

Prn Orders

A prn order is an order for a specific amount of a medication to be administered on an “as needed” basis rather than at a regularly prescribed interval. Typically, this medication is administered to treat a specific sign or symptom, such as pain, anxiety, fever, or constipation. Whenever an “as needed” dose is administered, healthcare personnel must immediately document the date, the time given, and the reason that the medication was administered.

Standing Orders

A standing order is a medication order in which the same set of medications and treatments applies for each patient who receives a similar treatment or surgery (see Figure 3.7). A physician or another prescriber may then sign this preprinted order or slightly modify the standing order by adding or deleting items before signing the form. For example, an orthopedic surgeon who specializes in knee replacement surgery may order the same medications, laboratory tests, and nursing directives for all patients having that procedure. Postoperative (postop) orders written after surgery are another example of standing orders.

Discharge Orders

A discharge order is an order that provides take-home instructions for a patient who is being discharged from a hospital. This order includes all prescribed medications and dosages. Prescriptions are commonly written for a seven-day or one-month period, or are designed to last until the patient’s follow-up visit with the healthcare practitioner.

Learning the Components of Medication Orders

Regardless of the type, each medication order must contain the same components. Similar to prescriptions, the legal requirements for information necessary on a medication order are regulated by state law and vary among states. Patient information, prescriber information, and medication information must be included on a medication order. You should also be aware that a facility’s policy may dictate additional parameters that must be included on a medication order.

Patient Information

Standard patient information on medication orders is highlighted in Figures 3.5, 3.6, and 3.7. This information includes the patient’s name, unique identification number, room number, birth date, and physician’s name. Patient information must provide sufficient data to uniquely identify the patient, thereby discerning one patient from another.

Other patient information may not be included on a medication order but needs to be accessible to personnel who participate in the management of a patient’s medications. This information may be accessed via the electronic health record (EHR) or patient chart. Patient information such as height, weight, allergy information, diagnoses, and current medications should be accessible. Information on pregnancy and lactation status and laboratory results should also be available, when necessary.

Prescriber Information

The signature and authority of the prescriber must be included on a medication order. Because many institutions utilize EHR and medication order entry systems, this signature may be electronic. Prescriber information is shown in Figures 3.5, 3.6, and 3.7.

Medication Information

Although prescriptions require the date, a medication order must include both the date and time of the order. The name of the medication, dosage, route of administration, and time or frequency of administration must also be included. Medication information is highlighted on the medications orders in Figures 3.5, 3.6, and 3.7.

Time of Day

Telling time is a skill that you learn as a child. For many individuals, this skill was taught using a clock with movable hands: one hand indicating the hours and one hand indicating the minutes. In addition to these traditional clocks, digital clocks that display the hours and minutes as numbers separated by a colon are also used to tell time. Digital clocks are commonly seen on computer software programs. Both types of clocks typically indicate what is known as standard time, or a system of time based on a 12-hour format. Standard time, also known as civilian time, uses the designations of a.m. and p.m.

The healthcare setting, including the pharmacy setting, uses a different time system known as 24-hour time. As its name indicates, this system is based on a 24-hour format and, consequently, does not use the designations of a.m. and p.m. In fact, most countries—with the exception of the United States and Canada—have adopted the 24-hour system as their official time standard.

The 24-hour system uses the numbers 0–24 to represent the 24-hour day. To provide consistency and prevent confusion, the 24-hour system uses four digits: The first two digits represent the number of hours past midnight; the last two digits represent the number of minutes past the hour. Times earlier than 10:00 a.m. will often be preceded by one or two leading zeros so that the hour has two digits. To see how 24-hour time compares with standard time, see Table 3.2.

The start of each day is designated as 0000, and midnight is designated as 2400. These two designations are actually the same time, so some computer systems will accept times up to 2400 and then require the first minute after midnight to be entered as 0001, thereby skipping the 0000 time display.

In the healthcare setting, the 24-hour system is used for accuracy. This system prevents ambiguity and provides a simple means of documenting the precise time in a 24-hour day. The 24-hour system may be used to document what time a medication is to be administered, what time an event (such as an adverse reaction) occurs, or what time an intravenous (IV) medication runs out. Precise minutes are also used, so if a medication is to be given at 6:30 a.m., it would be recorded as 0630 to indicate the exact time.

Figure 3.7 Standing Order

A physician saves time and aids hospital efficiency and communication by using a preprinted standing order form.

Because the healthcare system has adopted the 24-hour system, you need to become familiar with the time equivalents and be able to accurately convert times without looking at a chart. The times that occur in the morning hours are simple and straightforward because they are similar to the display on a typical digital clock. The times that occur in the afternoon and evening (1:00 p.m. to 12:00 a.m.) have numbers that many individuals are not accustomed to seeing when telling time: 1300 to 2400. For these 24-hour times, remember this simple rule: These designations can quickly be converted back to standard time by subtracting 1200. For example, if you subtract 1200 from 1900 hours, you get 7:00—the standard time designation for 7:00 p.m.

3.2 Problem Set

Match the following medication order type with its description below.

1. —— admission order

2. —— daily order

3. —— single order

4. —— stat order

5. —— prn order

6. —— standing order

7. —— discharge order

1. emergency order that is typically called in or sent electronically to a pharmacy

2. one-time order that is administered at a specified time

3. order for a medication to be administered regularly following the same instructions until the prescriber stops the order

4. order for a specific amount of a medication to be administered on an “as needed” basis

5. order in which the same set of medications and treatments applies for each patient who receives a similar treatment or surgery

6. order that provides take-home instructions for a patient who is being discharged from a hospital

7. order written upon patient admission to a hospital

Convert the following standard times to 24-hour times.

8. 7:30 a.m.

9. 4:28 p.m.

10. 12:45 a.m.

11. 9:20 p.m.

12. 2:24 a.m.

13. 10:58 p.m.

14. 11:50 p.m.

15. 1:20 a.m.

16. 12:03 a.m.

17. 12:20 p.m.

Convert the following 24-hour times to standard times.

18. 1730

19. 2349

20. 1522

21. 0034

22. 1204

23. 0355

24. 2245

25. 1719

26. 1300

27. 0145

Applications

28. Sun Ng, a patient who arrived in the emergency room around midnight, reported taking pain medication three times during the day: at 8:15 in the morning, at 1:15 in the afternoon with lunch, and at 7:00 in the evening. Using the 24-hour system, what times should be reflected in the patient’s health record?

29. A prescription states that Lucy Andrews, a pediatric patient in the intensive care unit, is to take medication three times a day, every eight hours, beginning at 5:00 a.m. Using the 24-hour system, what time should the medication therapy begin?

30. Dr. Dominic Estores has written a prescription for a patient to take a preoperative medication at 2200 on the evening before the patient’s scheduled surgery. Using the standard time system, what time should you tell the patient to take the medication?

31. The IV medications prepared each afternoon for overnight administration have to be delivered to the floors between 1800 and 1900. According to the clock in the pharmacy, when should you deliver the medications?

32. Ms. Singh has just been brought to the hospital via ambulance. During admittance, the patient reported placing one nitroglycerin tablet under the tongue at 3:00 p.m. and placing a second tablet under the tongue at 3:05 p.m. Because the chest pain didn’t go away, the patient placed a third tablet under the tongue five minutes after the second one. Using 24-hour time, determine the times that the patient placed the three tablets.

Self-check your work in Appendix A.