How to Transcribe A Doctors Order

1. Transcribing
Doctor’s
Order
By: Pamela M. Veroy RN, MAN

2. CARRYING OUT OF MEDICAL ORDER:
Objective: To be able to interpret intelligently doctor’s
order
Scope: This work instruction is to be done by a nurse
Medical Order – an order (written or verbal) made by
the physician pertaining care or management.
Work Instructions Detail:
1. Transcribes medical order to nursing Kardex.
2. Fills up instruction sheet, medication cards or ticket
and appropriate forms for laboratory and diagnostic
requests.

3. CARRYING OUT OF MEDICAL
ORDER:
1. If the nurse have any doubt regarding the
medical order, she will clarify it with the
attending physician who made the order.
2. Affix initials including date and time below it
has been carried out already.

4. How to interpret drug orders?
Make sure that the 5 rights are there in the
doctor’s order.
- right name of the drug
- right name of patient
- right dosage
- right time, frequency
- right route by w/c the drug
administered

5. Example 1:Procan SR 500 mg p.o. q. 6 h
1. Procan SR is the brand name of the
drug
2. 500 mg is the dosage
3. p.o. is the route
4. q. 6h is the frequency
This order means; Give 200 milligrams of
Procan SR orally every 6 hours.

6. How to interpret drug orders?
Example 2:Dilantin 100 mg p.o. t.i.d.
Read:___________________________________
_____
Example 3: procaine penicillin G 400,000 U IM
q.6h
Read:___________________________________
_____

7. Example 4: Demerol 75 mg IM q.4h, pain;
Read:__________________________________
Example 5: Pen-vee K 1 g p.o. 1h pre-op dental
surgery
Read:__________________________________
Other Doctor’s order for treatment:
1. 2/3 strength solution Ensure. Give 90 ml qh
for 5 hours via NG tube.
Read:___________________________________
____________________________________

8. 2. 5/8 strength solution Isomil 36 ml via NG tube
hourly for 8 feedings.
Read:___________________________________
____________________________________
3. Acetaminophen 240 mg. p.o. q4-6h p.r.n.,
pain or T>38⁰C.
Read:___________________________________
____________________________________

9. 3 Common Errors in Transcribing Medication
1. Incorrect interpretation of order due to
misunderstanding of traditional time.
• SITUATION:
• A physician ordered a mild sedative for an anxious Patient
who is scheduled for a colonoscopy in the morning. The
order read “Valium 5 mg orally at 6:00 x 1 dose.”
• The evening nurse interpreted that single dose order to be
scheduled for 6 o’clock PM along with the enema to be
given to the patient.
• The doctor meant for the Valium to be given at 6 o’clock AM
to help the patient relax prior to the actual test.

10. • 2. Failing to clarify incomplete orders.
• SITUATION:
• Suppose a physician ordered Pepcid tablet p.o. h.s. for a
patient with an active duodenal ulcer. You will note there Is
no dosage listed.
• The nurse thought the dosage came in only one strength,
added 20 mg to the order, and sent it to the pharmacy. The
pharmacist prepared the dosage written on the physician’s
order sheet.
• Two days later, during rounds, the physician noted that the
patient had not responded well to the Pepcid. When ask
about the Pepcid, the nurse explained that the patient had
received 20 mg at bedtime. The physician informed the nurse
that the patient should have received the 40 mg. tablet.

11. • 3. Not checking the correct dosage.
• SITUATION:
• A nurse flushed a triple central venous catheter (an
IV with three ports). According to hospital policy, the
nurse was to flush each port with 10 ml of normal
saline followed by 2 ml of heparin flush solution in
the concentration of 100 units/ml.
• The nurse mistakenly picked up a vial of heparin
containing 10,000 units/ml. Without checking the
label she prepared the label with all three ports. The
patient received 60,000 units of heparin instead of
600 units.

12. Critical Thinking Analysis
Reading the labels of
medications is critical, Make
sure that the drug you want is
what you have or hand before
you prepare it.

13. COLOR CODING OF MEDICINE TICKETS
COLOR FREQUENCY TIME
WHITE O.D. / STAT
PINK BID
YELLOW TID
BLUE QID/EVERY 4
HOURS
GREEN EVERY 6 HOURS
RED EVERY 8 HOURS
ORANGE PRN
HS
6-6/12-12
6-12-6
6-10-2-6
6-10-2-6-10-2
6-12-6-12
6-2-10
9 PM

14. MEDICINE TICKET
Objective: To be able to guide the nurse to follow the
doctor’s written order indication the drug to be given
the frequency of doses the amount of each dose and
the method of administration.
Scope:1. name of patient 5. name of drugs
2. age 6. route
3. room no. 7. time frequency
4. date 8. doses
(doctors’ name, NOD signature)

15. SAMPLE OF MEDICINE TICKET
MEDICINE TICKET
Date:_________________ Rm no.______ Bed no.______
Name:______________________________________
Drugs
Ordered:______________________________________________
____________________________________________________ .
Dosage:___________________________________________
Frequency:________________________________________
Route:___________________________
Dr:________________ NOD Sig.:_______________

16. Give me the color code….
Example:
1. Lasix 40 mg. IM stat --------------------
2. Motrin 600 mg. p.o. b.i.d. ------------
3. Tranxene 7.5 mg p.o. q.i.d. -----------
4. Tylenol w/ codeine gr. I p.o.
q. 4h p.r.n. for pain ---------------------
5. Inderal 50 mg. p.o. t.i.d. --------------
6. Amoxicillin susp. 100mg p.o.
q. 6 hrs. ------------------------------------
7. Oxacillin sodium 0.25 g p.o. q. 8 hrs-

17. Sample of Medication Sheet – MMGH
MEDICATION SHEET
NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______
NURSE’ FULL NAME/SPECIMEN SIGNATURE
Date Medication &
Treatment
Freq
PRN
STA
T

18. SAMPLE DOCTORS’ SHEET
_____________________________________________________________________
First Name Given Name M.I.
WARD:_________ROOM NO._______BED NO._______PHYSICIAN_________________
______________________________________________________________________
Date and Time: Time Remarks:
Ordered: Signature: ______
PROGRESS NOTES DOCTOR’S ORDER

19. SAMPLE DOCTORS’ SHEET
_Panduco Pedro__________________________P.____________
Last Name Given Name M.I.
WARD:_Wing A_ROOM NO. 212 BED NO._2__PHYSICIAN__Dr. Roberto de la Cruz_
______________________________________________________________________
Date and Time: Time Remarks:
Ordered: Signature: _____
PROGRESS NOTES DOCTOR’S ORDER
7-04-2008 - Give Lasix 40 mg. I.M. stat
(+) edema lower - Start Motrin 600 mg. p.o. b.i.d.
extremities ¥æ€
(+) rales on boths Dr. de la Cruz
Lungs; RR-26/min; BP 110/80 2:45 p.m.
7-05-08 - Tylenol w/ codeine gr. I p.o. q. 4h p.r.n. for pain
Complaint of headache ¥æ€
5:30 p.m. Dr. de la Cruz

20. Example: Transcribing Doctors’ Order in Medication Sheet
MEDICATION SHEET
NAME: _Penduco, Pedro__ Room:_212_ Bed No:_2_ Chart No.:_000123_
NURSE’ FULL NAME/SPECIMEN SIGNATURE
Date Medication &
Treatment
Freq 4 5 6
7-4-08 Motrin 600 mg. p.o. b.i.d. 6 ffl
6 ffl
7-5-08 Tylenol w/ codeine gr. I p.o. PRN
q. 4h p.r.n. for pain 6pm ffl
STAT
7-4-08 Lasix 40 mg. I.M. stat 3 pm ffl
ffl - Florence Nightale RN

21. SAMPLE OF DOCTORS’ SHEET
Panduco Pedro__________________________P.____________
Last Name Given Name M.I.
WARD:_Wing A_ROOM NO. 212 BED NO._2__PHYSICIAN__Dr. Roberto de la Cruz_
______________________________________________________________________
Date and Time: Time Remarks:
Ordered: Signature: _____
PROGRESS NOTES DOCTOR’S ORDER
7-06-08 - Tranxene 7.5 mg p.o. q.i.d.
Leukocytes –CBC result - Oxacillin sodium 0.5 g p.o. q. 8 hrs-
- D/C Motrin ¥æ€
9:30 a.m. Dr. de la Cruz

22. Example: Transcribing Doctors’ Order in Medication Sheet
MEDICATION SHEET
NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______
NURSE’ FULL NAME/SPECIMEN SIGNATURE
Date Medication &
Treatment
Freq 4 5 6
7-4-08 Motrin 600 mg. p.o. b.i.d. 6 ffl D C 7-6
6 ffl
7-5-08 Tylenol w/ codeine gr. I p.o. PRN
q. 4h p.r.n. for pain 6pm ffl
STA
T
7-4-08 Lasix 40 mg. I.M. stat 3 pm ffl
ffl - Florence Nightale RN

23. Example: Transcribing Doctors’ Order in Medication Sheet
MEDICATION SHEET
NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______
NURSE’ FULL NAME/SPECIMEN SIGNATURE
Date Medication &
Treatment
Freq 6 7 8
7-06 Tranxene 7.5 mg p.o. q.i.d. 6
10 ffl
2 ffl
6
Oxacillin sodium 0.5 g p.o. q. 8 hrs 6
2 ffl
10
ffl - Florence Nightale RN

24. SAMPLE OF DOCTORS’ SHEET
Panduco Pedro__________________________P.____________
Last Name Given Name M.I.
WARD:_Wing A_ROOM NO. 212 BED NO._2__PHYSICIAN__Dr. Roberto de la Cruz_
______________________________________________________________________
Date and Time: Time Remarks:
Ordered: Signature: _____
PROGRESS NOTES DOCTOR’S ORDER
7-06-08 - Tranxene 7.5 mg p.o. q.i.d.
Leukocytes –CBC result - Oxacillin sodium 0.5 g p.o. q. 8 hrs-
- D/C Motrin ¥æ€
9:30 a.m. Dr. de la Cruz
7-07-08 - Continue Oxacillin 0.5 g p.o. q8h for 4 doses and D/C
¥æ€
12:30 a.m. Dr. de la Cruz

25. Example: Transcribing Doctors’ Order in Medication Sheet
MEDICATION SHEET
NAME: ___________________ Room:_________ Bed No:_______ Chart No.:______
NURSE’ FULL NAME/SPECIMEN SIGNATURE
Date Medication &
Treatment
Freq 6 7 8
7-06 Tranxene 7.5 mg p.o. q.i.d. 6 ffl
10 ffl ffl
2 ffl
6 ffl
Oxacillin sodium 0.5 g p.o. q. 8 hrs 6 ffl
1 – 2 – 3 - 4 2 ffl ffl
10 ffl
ffl - Florence Nightale RN

26. SAMPLE FORMAT OF MEDICINE TICKET-MMGH
Room No. ________________ Date:_______________
Name:_____________________________ Age:______________
Order:_________________________________________________________
Route: ________________________________________
Frequency:____________________________________________
Dr.___________________________ Sig.__________________________

27. SAMPLE FORMAT OF MEDICINE TICKET
Room No. ________________
Name:_________________________________________________________
Room No.______________________ Bed No._______________________
Drug:__________________________________________________________
Dosage/Freq:____________________________________________________
Route:________________________ NOD:_________________________

28. SAMPLE FORMAT OF MEDICINE TICKET-MMGH
Room No. _212-2__ Date:___7-06-08______
Name:___Penduco, Pedro__________ Age:__22_________
Order: __Tranxene 7.5 mg p.o. q.i.d. ____
Route: __per orem_____
Frequency:_______6 – 10 – 2 - 6______________________
Dr._Dr. de la Cruz_______ Sig.___ffl______

29. SAMPLE FORMAT OF MEDICINE TICKET
Date __7-06-08_____
Name:___Penduco, Pedro__________________________
Room No.__ 212____ Bed No.__2____
Drug:_Amoxicillin susp.100mg p.o. q. 6 hrs._
Dosage/Freq:__6 – 12 -6 - 12________________________
Route:___oral______
NOD:____ffl_________

30. Irregularities in Transcribing MT
• If the order is PRN with varied time frequencies
• If the order is stat and then with regular time
frequency
• To indicate dosage; you can write – name of drugs,
strength (dosage), time frequency
• Stat order to be administered less than 1 hr. on a
• Medicine ordered with a series of doses should also
write no. of dosage done on the ticket

31. Example situation
Date __7-06-08_____
Name:___Penduco, Pedro__________________________
Room No.__ 212____ Bed No.__2____
Drug:_Amoxicillin 500mg IVTT q. 6 hrs. x 6 doses_then shift to
p.o.
Dosage/Freq:__6 – 12 -6 - 12__________________
Route:___IVTT______
1-2-3-4-5-6 NOD:____ffl_________

32. Keys to Remember:
1. Never transcribe doctors’ order in a medicine ticket with
erasures or tampered.
2. Always write legibly, neatly, and correctly.
3. Do not recycle the used medicine ticket. (as much as
possible)
4. A new doctors’ order is a new medicine ticket.
5. Endorsed to your charged nurse the old ticket that has
changed order in; (increase/decrease dosage; route)
6. Do not revise/rephrase what have written in the doctors’
order. Rewrite completely what have written in the order.
7. If in doubt; check your ticket from the doctors’ order sheet
first before in the medication sheet.

33. 8. Arrange your drugs according to their color coding if for 1
patient with lots of drugs in different frequencies/timing.
9. Make an indication/marks on the medicine ticket for stat
orders; to prevent from administering twice.
10. Signing the medication sheet as prompt as possible after
administering/given a due medicines.
11. Do not sign the medication sheet in advance; without
administering the drugs yet. Especially IVTT meds.
12. Always coordinate with the charge nurse with regards to
new orders; new drugs ordered; etc.
13. Be mindful always……

34. Drugs just like a
sword that has two
sharp edges;
Whether it heals
you, or kill you for
just a minute from
miscalculation.