Date: __________

Name: __________ Age: ___ Wt: ___

Address: __________
Rx:
Dispense 21 capsules
Sig: Take 1 capsule 3x a day after meals
fr 1 !eek fr acute tnsilitis
_______________"#D#
Refill _____ time$s
1
PRINCIPLES OF PRESCRIPTION ORDER WRITING
Classes of Prescription Orders
o Precompounded
One that calls for dru or mi!ture of
drus supplied "# pharmaceutical
compan# "# its o$cial or proprietar#
name and in the form that the
pharmacist dispenses %ithout
alteration
o Compounded or E!temporaneous
T#pe in %hich the ph#sician selects
the drus& doses and pharmaceutical
form desired and the pharmacist
prepares the medication
Prescription pad "lan's normall# are
imprinted %ith a headin that i(es the
name of the ph#sician and the address and
phone num"er of the practice site
Parts of a Prescription Order)
o Superscription
Date the prescription order is %ritten
Name& address& %eiht and ae of
the patient
R!) an a""re(iation for the latin %ord
*recipere+ meanin *ta'e+ or *ta'e
thus+ as a direction to the pharmacist&
precedin the ph#sician,s *recipe+ for
preparin a medication
o
o Inscription
The "od# of the prescription&
contains the name and amount
strenth of the dru to "e dispensed

o *Si+ or Sina
The instruction for the patient as to
ho% to ta'e the prescription
The "est directions to the patient %ill
include a reminder of the intended
purpose of the medication unless its
inclusion %ould em"arrass the
patient
The correct route of administration is
reinforced "# the choice of the -rst
%ord of the directions

o Re-ll
Schedule II drus
% No re-ll under an# circumstances
Schedule II and I. drus
% Re-lls ma# "e issued& not to
e!ceed / re-lls or 0 months after
the issue date& %hiche(er comes
-rst
Schedule . drus
% No restrictions on the num"er of
re-lls allo%ed
o Prescri"er,s sinature
Rules to Follo% in Writin a Prescription
o Choice of a drug name
Generic name
% In the 1S& this is the 1S 2dopted
Name or 1S2N
Trade name& trademar' or "rand
name
% 3anufacturer,s proprietar# name
o Choice of a system of weights and
measures
2ll orders should "e %ritten usin
metric measurements of %eiht and
(olume
2ra"ic 4decimal5 numerals are
prefera"le to Roman numerals
1se leadin 6eros 4789:/ m5; ne(er
use trailin 6eros 497 m not 9787
m5
o Abbreviations
2(oid a""re(iatin dru names since
this leads to numerous errors due to
sound<ali'e names
2(oid a""re(iatin directions for
dru administration& %rite directions
clearl# in Enlish
o Orthographic and phonologic
similarities of dru names account for
:/= of medication errors
Includin the therapeutic purpose
and> or patient,s dianosis can
pre(ent dispensin errors

2
o Poor handwriting is a %ell<'no%n and
pre(enta"le cause of dispensin errors
o All prescriptions should be written
in ink
Erasures on a prescription easil# can
lead to dispensin errors or di(ersion
of controlled su"stances
o The amount to be dispensed should
"e clearl# stated and should "e onl# that
needed "# the patient
Writin Orders for ?ospitali6ed Patients
Ph#sician,s orders indicate)
o What the ph#sician "elie(es to "e the
ma@or reason for a patient,s
hospitali6ation
o The seriousness of the pro"lem
Hospital Order outlines
o Dianostic e(aluation
o Therapeutic inter(entions
Rules in %ritin ?ospital Orders
o 2dmission orders should "e written
promptly after e(aluation of the patient
o Order must "e written in ink and must
"e legible and clearl# con(e#ed so that
there can "e no misinterpretation of the
intended plans
o Each set of orders should "ear the date
and time %ritten and the legible
signature of the ph#sician
o Orders should "e reviewed daily and
updated as necessar#
The content and orani6ation of admission
orders follo% a routine to ensure that no
important therapeutic measures are
o(erloo'ed
o 2DC .22N DIS3L
o Admit) included is the location as to
%here patient is to "e admitted and the
physician responsi"le for the patient
o Diagnosis) if the dianosis cannot "e
i(en #et& the chief complaint can "e
used
o Condition) this is a clinical estimate
made "# the admittin ph#sician %hich
should "e updated as the patient,s
clinical condition chanes
Good A implies that the patient is
sta"le and that there are no
anticipated complications
Fair A implies that the patient is ill
and ma# ha(e complications "ut has
a ood chance for reco(er#
Poor A patient is (er# ill& ma# ha(e
complications and is not (er# sta"le
OR patient is chronicall#> terminall#
ill and is not e!pected to do %ell
erious A patient is (er# ill and not
(er# sta"le and the clinical outcome
is not predicta"le
Critical A usuall# implies that the
patient is desperatel# ill& (er#
unsta"le and ma# not reco(er&
usuall# placed on a *D2NGER LIST+
o !ital igns) routine (ital sins include
temperature& pulse rate& respirator#
rate& BP
FreCuenc# and parameters for
noti-cation of attendin ph#sician
must "e speci-ed
The clinical condition of the patient
%arrants freCuenc#)
% E(er# 97<9/ minutes for criticall#
ill patients
% E(er# D hours for sta"le patients
These orders should be reviewed
daily so that if lesser freCuenc# is
appropriate& the nursin staE can
focus on patients %ho need more
nursin care
Activity" amount of acti(it# is
decided "# the attendin ph#sician
"ased on the patient,s clinical status
% Complete bed rest %ithout
toilet pri(ilees A 3I and C?F
% Complete bed rest %ith
"edside commode
% Out of bed %ith assist
% #nimpeded acti(it#
o Allergies$ sensiti(ities or pre(ious dru
reactions) ma# "e %ritten in red ink
o %ursing &nstructions
I and O
Fole# catheter to ra(it# drainae
Wound care
Dail# %eihts
o Diet" man# patient (aria"les should "e
'ept in mind in determinin the nature
of nutritional support
9
st
decision %hether or not a patien
ma# ta'e an#thin "# mouth
% %PO) 2ltered state of
consciousness
Fear of aspiration
Planned surical or la"orator#
procedures
Suspected a"dominal
patholo# that ma# "e

3
%orsened "# eatin and>or
drin'in
% Clear li'uids O( Full li'uid
diet
% Full diet or oft diet
Once a diet has "een chosen& the
ph#sician must determine an#
restrictions to the diet
% 2ppropriate restrictions of
calories and car"oh#drates for
diabetics
% 2ppropriate restrictions of
allerenic foods for asthmatics
and those %ith histor# of food or
dru alleries
% Salt restrictions for edematous
patients
o &ntravenous Fluids) include
composition and rate
)acrodrop set) D drops> cc
)icrodrop set) drops>min F cc>hour
Composition of I.F depend on
patient,s needs
o edatives$ analesics and other per
reCuest medications
o )edications" dose& freCuenc# and
route of administration
o *aboratory tests and radioraphic
studies
Dischare Orders
o Dischare order
o Dischare dianosis
o Condition on dischare
o Dischare medications
o *Prescriptions %ritten+
o Follo%<up
o Diet
o 2cti(ities allo%ed
o Special instructions
Commonl# 1sed 2""re(iations
Dianosis
o D!) dianosis
o DD!) diEerential dianosis
o 2LL) acute l#mpoc#tic leu'emia
o 23L) acute m#eloenous leu'emia
o COPD) chronic o"structi(e pulmonar#
disease
o C2PD) chronic am"ulator# peritoneal
dial#sis
o D.T) deep (ein throm"osis
o TI2) transient ischemic attac'
o R>O 3I) rule out m#ocardial infarction
o ?ONC) h#perosmolar non'etotic coma
o ?PN) h#pertension
Nutrition
o NPO) nothin "# mouth
o ad li") as much as desired
Drus and dosaes)
o r) rains
o mc) microram
o m) milliram
o m) ram
o ta") ta"let
o cap) capsule
o lpm) liters per minute 4o!#en5
o mil) million
o tts) marodrops
o utts) microdrops
Time inter(als
o Cod) e(er# other da#
o Cd) e(er#da#
o "id) t%ice a da#
o tid) three times a da#
o Cid) four times a da#
o hs) at "edtime
o ac) "efore meals
o pc) after meals
o prn) as needed
Routes of administration
o PO) "# mouth
o PR) per rectum
o SC) su"cutaneousl#
o I3) intramuscularl#
o I.) intra(enousl#
La"orator# tests
1TG) ultrasound
CHR) chest !<ra#
TP2G total protein and al"umin
PFT pulmonar# function test
3RI manetic resonance imain
TET treadmill e!ercise test
Ph#sician,s Order
Date
I>7J>7
J
97am
Please admit 3r8 Noh Pe#n to IC1 under
Dr8 3asa Kuinton,s ser(ice
D!) Chest pain R>O 3I
Condition) POOR
.ital Sins) TCDh
?R& RR C L7 min
BP C 9 h
Pls8 refer if ?RM977>min& RRML7& s#stolic
BPNO7mm? or M9D7
2cti(it#) CBR %>o BRP
2lleries) none
Strict I P O C shift) pls record accuratel#
?ih "ac' rest
2nti<em"olic stoc'ins

&
Pls8 limit (isitors
Lo% salt& lo% fat diet
Start I.F %> D/W /77cc at 97cc>h
3orphine 97m ta" 9 ta" e(er# 9:h prn
for chest pains
7: inhalation at :L>min (ia nasal canula
La"s) CBC
1rinal#sis
CPQ<total
CQ<3B
Serum creatinine
B1N& RBS
Serum Na& Q>Ca& 3
Lipid pro-le
EQG
CHR 4P25
Pls8 notif# attendin 3D and RIC of
admission

SIGN2T1RE