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Order transcription

Posted

Has 14 years experience.

I am auditing charts and noticed that someone took of an order and it was a qd order. He put qam. Is that a no no? I wouldn't have done it that way. I almost feel like it is changing the order.

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 16 years experience.

There may be policies and protocols that spell out when once a day meds are given. For example, my facility utilizes 9am for once a day meds (unless they need to be given at bedtime) and 9am and 9pm for twice a day meds. The way it's transcribed, it's still once a day but prevents, for example, one nurse giving it at 7am and another nurse giving it at 7pm the following day. Refer to your policies for the final answer.