Completing an MD Order

by Edward Lara Leave Comment

MD Order Form

One of the major causes of medication errors occurs between the person giving the orders, the understanding of what is said and the writing of the order. These miscommunications have the potential of being devastating to the client if a wrong medication or dose is given. This is especially true when one considers the majority of our clients are pediatric and even the smallest error can impact the outcome of the client.

This new form will remind us and prompt us to gather the information more accurately, completely and with additional safe guards to ensure the clarity of all orders. Please replace the old forms in the home with the new ones we have devised.

HOW TO USE

  1. Complete the client’s name and date of birth.
  2. Complete the name, address, phone number and fax number of the physician responsible for the orders.
  3. Remember to write the orders without the use of the prohibited abbreviations as listed on the form.
  4. Write the orders down on the form LEGIBLY.
  5. Read back orders to the physician or their delegate to confirm accuracy. This means you have written the order down and are READING it back not just repeating it back.
  6. Keep in mind and pay close attention if any of the orders contain any look alike or sound alike medications.
  7. Spell back all medications if there is any question of their spelling.
  8. Indicate who gave the order. Get their first and last names and credentials. Place this information in the area: “Orders given by..” Date the order.
  9. Sign the order with your credentials and date it.
  10. Check the box indicating that you did indeed read the orders back to verify accuracy.
  11. Indicate the purpose of the medication/order on the MD order form: “Client status/reason for order.”
  12. Determine the purpose of the medication before administration.
  13. Complete the loop: provide the new orders to the oncoming care- givers, include a copy of the order in the chart, add the new order onto medications administration sheets or task sheets as appropriate, include the information in the communication book, report the new order verbally to the next caregiver and why it was ordered, inform suppliers if needed, send the original into the office.
  14. AND don’t forget to provide instruction and education to the client/caregiver regarding a new medication, side effects, adverse reactions, dosage, etc.
  15. Indicate you teaching directly on the MD order form.

By Janet Fulfs, President

Also, please see video below: