Who transcribes med orders?

[AHarri66]

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!

[healingtouchRN]

what unit sec? not one in our budget....I guess I'm it!

[Keysnurse2008]

the unit secrestary does ...and the primary care rn double checks the orders for errors

[gwenith, BSN, RN]

Over here in Australia who transcribes the drugs is detailed in the state therapeutic goods act - here it is the doctor who has to sign it within 24 hours or they get fined!!!!! RN transcribes with another checking. In practice the doctors write new med sheets.

Personally I would check your local equivalent of a therapeutic goods act. Here are a couple of websites that might help work out the legalities underpinning this problem.

http://www.ahrq.gov/qual/errorsix.htm

http://www.ismp.org/

http://www.jcaho.org/

http://www.mederrors.com/

http://medicalerrorreduction.com/

[Marie_LPN, RN, LPN, RN]

Whoever can READ them transcribes them for us.

[cg6303]

I work on a medical tele/ stepdown unit in a fairly large Level 2 trauma center and the MD writes orders-secretary takes off orders and enters them into computer or faxes to pharmacy- but we have computerized MAR's that pharmacy sends out every evening - the primary nurse must check that the orders were entered into computer by secretary correctly and also must check computerized MAR's at night with 12 hr chart check to ensure pharmacy was correct in their interpretation of the MD's handwriting. Its a lot of work for each shift but we have noted a decrease in errors with the computerized med sheets vs. handwritten. I think still that the doctors should have to PRINT instead of being "fancy" and that transcription errors would decrease further- this is yet to be seen!!!!!!:)

[Nurse89]

Nurse (RN or LPN) transcribes.

Noc Nurse does 24h checks.

Forwarded to pharmacy who sends new MAR's.

[RNKPCE]

We have had a computer system for over 20 yrs at our hospital. Initially the older docs would still write there orders. Over the last 10 years we hardly ever transcribe orders. Most of the doctors can put orders in the system from their office and they do it. The only times we seem to transcribe orders if when a doctor does a direct admit from his office and he/she doesn't have the ability to enter orders from his office. In those instances the ward clerk might enter them, the charge nurse or the patient's nurse. They are then double checked by another nurse.

[pwp1289]

we are all computerized-md writes order goes directly to floor pharmacist who verifies it for correctness(route,cap vs tab,po vs im etc)it is then verified by rn before being given by med nurse--also via computer using bar coding system

[Shellsie]

heres how it goes in our little hospital

1. md writes order

2. unit secretary enters orders in computer that need entered and writes the med orders on the MAR. she places the chart on the rack

3. the nurse checks the orders...makes sure the labs are in the computer and meds are transcribed correctly and then she signs off the order.

ultimately the nurse is responsible...we do 12 hour chart checks also

[AlixCoastRN]

Long-term care facility -

The charge nurse takes off the order and faxes it to pharmacy

The RCM (aka MDS, care manager) reviews the order the next day

At the end of the months all physicians orders are printed by medical records, reviewed for correctness/audited, the sent to the MD for signature. The med and tx sheets are printed at the same time and audited. This is done by and RN.

[MandyInMS]

Originally posted by LPN2Be2004

Whoever can READ them transcribes them for us.

LMAO...so true..sometimes ya havta turn your head sideways to read some of our MD's orders

[autumn-moon]

State acute care psych hospital.

MD writes, primary RN (usually)or other available RN notes it in chart and transcribes into MAR.

Order faxed to pharmacy.

Each shift does at least one informal chart check with 11-7 doing written 24hr. check.

Chart audit done 1x/mo. by (usually) primary RN

Pharmacy also sends computerized MAR sheets 1x/mo. for chart audit.