Exam V: Order Writing Flashcards Preview

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Flashcards in Exam V: Order Writing Deck (6)
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1

ABC DA VANDILISM

A = Admit to surgical service 6th floor
B = Because- diagnosis/reason patient is being admitted
C = Condition- good, fair, serious, critical

D = Diet- range of NPO to regular
A = Activity- ranges from bedrest to ambulating

V = Vitals- frequency of vitals recorded
A = Allergies and Adverse Reactions
N = Nursing- checks and exams
D = DVT Prophylaxis- especially if impaired mobility
I = IVs- how much fluid and over what period of time
L = Labs
I = Inputs and outputs- monitoring hydration
S = Special- imaging, consults, dressings, foley, etc.
M = medications- name, dosage, frequency, and route

2

Components to Prescription Writing

1. The reason for the medication
2. Identification of the medication
3. Instructions on how to take the medication
4. Amount of medication to give
5. Number of refills to give
6. Your LEGIBLE name & Signature
7. Date

3

Prescription: First Line

Drug Name
Forms - Tablets, capsules, redi-tabs, suspensions, ointments, creams, gels, lotions
Milligrams, milligrams/milliliter, concentrations

*Make sure you avoid mistakes by writing 0.5 instead of .5, or writing 5 and not 5.0

4

Prescription: Second Line

SIG: instructions on how to take it

Has 3 components
Amount - one, two, one tsp, 5 cc, one ounce, 30 cc, 2 gtts
Route - PO, PR, PV, SL, Transdermal, SQ, IM
Frequency - q 1 hour, q 8 hours, q 72 hours, qd, bid, tid, qid, qod, prn, until gone

5

Prescription: Third Line

Dispense
Amount: number, cc, vials
Put a line after number so it cannot be changed (Ex: 30 can’t be turned into 300)
May be better to write out amount (Ex: thirty)
Usually prescribed in 30 or 60 day supplies
Example: 1 tablet BID dosing would need 60 tablets

6

Refills

Also better to write out (Ex: one)
Write out “None”
New medications usually get very few refills to allow appropriate reevaluation
Chronic medications: up to 1 year of refills