Who transcribes med orders?

[AHarri66, BSN, RN]

Our facility has recently made changes regarding medication transcription (among a million other things, it seems!), and I was curious how other places do it.

Who transcribes medication orders where you work?

What kind of second-check procedure do you use, ie. another nurse, charge nurse, 24hr checks, etc.

If you could mention what type of facility you work in, that would be helpful!

Thanks all!

[Anaclaire]

Level III NICU ~ The nurse assigned to the baby is responsible for transcribing the medication order onto the Medex. We also calculate the dosage and write it there too. A second RN or LPN must also check the order in the chart and compare it to what's written on the Medex, calculate the dosage too, and then both nurses place their initials on the Medex.

Mother-Baby Unit ~ The primary nurse was responsible for her patient's medication orders being placed on their Medex, whether she or another nurse (LPN or RN) actually did the transcribing. Two nurses had to initial the Medex verifying the order was transcribed correctly.

May I ask, what changes has your facility made recently, and what type of facility do you work in?

[zambezi, BSN, RN]

CCU- Dr writes orders or RN writes verbal order, unit secretary often sends order to pharmacy but it is primary RNs job to review order...Pharmacy puts patients profile in the omnicell but it is still primary RNs job to give right meds...night shift checks new MARS for accuracy, sends clarification orders to pharmacy, and does 24 hour chart check...throughout the day if there are changes, MAR /pharmacy is updated prn...

[altomga, ADN, BSN, MSN, DNP, RN, APRN]

The unit secretary is the one who normally transcribe's orders. The RN's do 12hr chart checks, the secretary does 24hr chart checks. If a MEDEX is rewritten it is checked by a second person.

At night the nurses usually writes the order on the medex themselves though if it's a already residing pt. We are the ones who called the doc to get the med, so we write it down ourselves.

I work at a level I trauma center...>700 bed facility.

I personally work on the step down medical ICU floor.

[Chaya, ASN, RN]

(Rehab) RN, LPN, or unit sec transcribes order. Orders transribed by unit secretary are left flagged and co-signed by nurse. Each nurse does a shift check on all her patients' charts. Night nurse does a final 24 hr check on all.

[Rapheal]

The RN who is taking care of the patient the meds are ordered for. Must calculate times. The we fax the order to pharmacy, then we call pharmacy when it has not come up. Then we call pharmacey again when it has still not come up, and so on and so on.

[niteshiftnurse]

Unit secretary. nurses do 24hr chart check and catch anything the secretary misses

[AHarri66, BSN, RN]

Originally posted by Anaclaire

...May I ask, what changes has your facility made recently, and what type of facility do you work in?

Ooops, sorry! :imbar

I work on a Med-Surg/Tele floor in an acute care community hospital. We have moved from a system where the unit secretary transcribed orders to the Medex and the charge nurse (usually) or primary nurse signed them off and set the schedule. Then we went to a system where the unit secretary transcribed, and the primary nurse signed them off and scheduled. Now the primary nurse is responsible for transcribing, signing off, and scheduling his/her own orders. There is no policy in place for second-check EXCEPT for 24hr checks, which are done on the night shift.

The reason for the change is supposedly to cut down on transcription related errors, but a bunch of us are wary, mostly of the second-check procedure. Just this weekend I found three transcription related errors, and those were only the ones I found. Thankfully, there were no adverse effects! :uhoh21:

[MandyInMS]

I work in a small town hospital. The primary nurse is responsible for all orders taken off.We have no ward clerks anymore :/ Night shift primary nurse of said pt. does 24 hr chart check.

[ga.bones]

Large acute care hospital. Primary nurse transcribes all orders, secretary puts in the computer labs, xrays,etc, then primary co-signs that. More time away from the bedside!

[whipping girl in 07, RN]

Medium size acute care hospital, ICU.

Unit secretary (day shift only) transcribes all orders except meds/IVs, then primary nurse signs them off.

Primary nurse transcribes meds/IVs, faxes to pharmacy and signs them off.

On night shift, there is no unit secretary, so primary nurse does everything, and chart check is also on night shift.

[live4today, RN]

Unit secretary transcribes all orders, and the RN signs them off and checks for accuracy.