Policy Update: Medication Order Management

The highlights...please refer to the policy on Meditech for full text.

Medication orders must include:

• Date and time order was written
• Drug name, dosage, unit of measure, route of administration, and frequency
• PRN orders must have a clearly stated indication. Multiple therapies for the same indication are not accepted.
  
• Range orders must contain only one set of range limits (replaces policy for Range Orders Standard #13.026).

Order must be clarified if:

• The order is incomplete, unusual, illegible, or unclear (includes look alike/sound alike)
• Contrary to current prescriptive recommendations
• Contraindicated for the pt's condition
• At risk for drug interactions

When transferring level of care:

• Form #17 required for transfer to different level of care, or after surgery.
• The sending unit must take off all transfer orders.
• NOT ACCEPTABLE: "resume all meds" or any other blanket orders.

Telephone and Verbal orders:

• Verbal orders are only acceptable when the prescriber is not physically present
• Orders must be read back for verification
• Document: Physician's name, name of person relaying the order, and date/time. Use acceptable abbreviations.
• Orders are signed off once they are transcribed
• Verbal and telephone orders will be flagged at the time of transcription to signal the MD to sign the order.

Taking off orders:

• Orders can be signed off by an RN or UC. You must "bracket" the order from top to bottom, then sign and time/date.
• When double-checking orders that have been transcribed by a UC, the RN must bracket them and include a date, time, and signature.

Please reference the policy for a list of who is allowed to take a verbal order (in addition to RNs). Use the rule of thumb: If it is outside the scope of practice to administer the medication, it is outside the scope to take a verbal/telephone medication order.

Reference: Medication: Order Management, Standard #13.029