TRANSCRIBING ORDERS

Question 1

It is making a written copy of the doctor’s order for proper implementation of clients care and treatment. Nurses are legally responsible for carrying out the orders of the doctor in-charge unless the orders would result in client’s harm

Answer 1

TRANSCRIBING ORDERS

Question 2

It is a written medical regimen of patient, which includes medications , treatment, diagnostic and surgical procedures and health instructions given by any accredited physician during patient confinement.

Answer 2

TRANSCRIBING ORDERS

Question 3

All doctor’s order must be written in

Answer 3

pen not in pencil.

Question 4

Have all entries countersigned by the

Answer 4

Clinical Instructor

Question 5

In case of error, draw

Answer 5

a single horizontal line on the error and write the correct word beside it.

Question 6

Materials and forms needed

Answer 6

Patient’s Chart with Physician’s Order Sheet
Nursing Kardex 1 & 2
Medicine Cards / Flaggings (Assorted Colors)
Medicine Sheet
Prescription Pad
Request Slip (for other departments)
Various Forms / Sheet
Black and Red Pens
Ruler
Pencil with Eraser

Question 7

YELLOW –

Answer 7

internal medicine

Question 8

GREEN –

Answer 8

SURGERY / EENT

Question 9

BLUE –

Answer 9

Ob and gyne

Question 9

PINK –

Answer 9

PEDIA

Question 10

“SIGNATURE OVER PRINTED NAME”

Answer 10

Charting
Prepared by:
Requested by:
Printed name and signature
Signature over printed name
Staff Nurse
Staff Nurse on Duty

Question 11

“FULL SIGNATURE”

Answer 11

Nurses Signature
Countersigning doctors order
Medicine Cards

Question 12

“INITIALS”

Answer 12

Medication Sheet
Nursing Kardex
Per physician in the prescription pad

Question 13

BLACK INK

Answer 13

7 – 6:59 = 7am – 6:59 pm

Question 14

RED INK

Answer 14

7 – 6:59 = 7pm – 6:59 am

Question 15

AM Shift

Answer 15

(8am to 4pm)

Question 16

PM Shift

Answer 16

(4pm to 12mn)

Question 17

NOC Shift

Answer 17

12mn - 8am

Question 18

BLUE CARD

Answer 18

Bladder Training
Charges of Medical Equipment / Devices Used
Serial Monitoring of Blood Extraction
Compression Stockings
24Hr Urine Collection
Weaning
Special Endorsement
Borrowed Items, Medical Certificate, Medical Abstract, Reminders, etc.

Question 19

GREEN CARD

Answer 19

I.V.T.T. / Direct IV / Bolus ONLY

Question 20

YELLOW CARD

Answer 20

Infusion / Drips ONLY

Question 21

PINK CARD

Answer 21

Blood / Blood Components

Oxygen

Question 21

Prescription

Answer 21

Date
Name
Age
Sex
Room number
Address

Generic Name
Brand Name
Dose
Quantity
Form
Doctors Name / Countersign
License and PTR if needed
Full name and Signature of the Folks / Patient

Question 22

Standing Order

Answer 22

Given on a regular basis until the order is discontinued.
Make a medicine card and indicate the standard timing (OD, Q4Hrs etc.)
Written on a separate medicine sheet for intended for standing medication.
The timing or specific time is not written unless administered.

Question 23

PRN Order

Answer 23

Given when needed or as requested only. Make a medicine card but do not write standard timing. Written on a standing medications sheet..

Question 24

PRN Medication Cards are placed in the

Answer 24

Kardex.

Question 25

Pre-procedure Order

Answer 25

Given before the procedure or operation as ordered. Make a medicine card but do not write standard timing Written on a STAT / SINGLE DOSE / PRE PROCEDURE medication sheet..

Question 26

Pre-procedure Medication Cards are placed in the

Answer 26

Kardex.

Question 27

STAT / Single Dose Order

Answer 27

Should be given immediately / given only on a specified time. Make a medicine card and write the time given. Written on a separate medicine sheet for STAT / SINGLE/ PRE-PROCEDURE.

Question 28

DISCONTINUING MEDICATIONS:

Answer 28

1. Card out present medicine card. 2. In the medicine sheet, draw a red line from the last dose of the medication administered up to the second to the last column. On the last column, write “D/C” and the date discontinued below it. 3. In the Nursing Kardex 2, place a red line on the medication to be discontinued and write “D/C” and the date discontinued on top of the red line.

Question 29

CHANGING TIMING OF MEDICATIONS:

Answer 29

1 Card out present medicine card and make a new card indicating the time. 2 In the medicine sheet, draw a red line from the last dose of the medication administered up to the second to the last column. On the last column, write “Changed Timing” and the date of changed timing below it. 3 Make a new entry in the medicine sheet indicating the new timing and draw a black line from the entry until the date of changed timing. 4 In the Nursing Kardex 2, place a red line on the medication to be changed timing and write “Changed Timing” and the date of changed timing on top of the red line. 5 Make a new entry on the Nursing Kardex 2 and indicate the new timing.

Question 30

SHIFTING / REVISION OF MEDICATIONS :

Answer 30

1 Card out present medicine card and make a new card. 2 In the medicine sheet, draw a red line from the last dose of the medication administered up to the second to the last column. On the last column, write “Revised / Shifted” and the date shifted / revised below it. 3 Make a new entry in the medicine sheet indicating the new timing and draw a black line from the entry until the date shifted / revised. 4 In the Nursing Kardex 2, place a red line on the medication to be shifted / revised and write “Revised / Shifted” and the date on top of the red line.. 5 Make a new entry on the Nursing Kardex 2 and indicate the new timing.

Question 31

Laboratories flow

Answer 31

TREATMENT CHART NURSING KARDEX 1 ENCODE IN COMPUTER LABORATORY REQUEST SLIP

Question 32

Pulmonary

Answer 32

TREATMENT CHART MEDICINE CARD MEDICINE SHEET NURSING KARDEX 2 PRESCRIPTION PAD

Question 32

Diagnostic Exam flow XRAY ECG ABG

Answer 32

TREATMENT CHART NURSING KARDEX 1 XRAY REQUEST ECG REQUEST ABG REQUEST *attach PAR

Question 33

Diagnostic Exam ULTRASOUND 2D ECHO EEG OTHER DIAGNOSTICS

Answer 33

TREATMENT CHART NURSING KARDEX 1 DIAGNOSTIC EXAM UTZ REQUEST CARDIOVASCULAR REQUEST EEG REQUEST *attach PAR BOOKING CONSENT

Question 34

DIETARY

Answer 34

TREATMENT CHART NURSING KARDEX 1 REPORT TO DIETARY DEPARTMENT

Question 35

SPECIAL ENDORSEMENTS

Answer 35

TREATMENT CHART BLUE CARD REFER IF NEEDED

Question 36

NURSING PROCEDURES Important Points

Answer 36

Check and Verify Doctor’s Order Prescribe Materials Countersign orders once orders are carried out. Gather Equipment Perform Hand Hygiene Explain the procedure Provide Privacy Document Refer

Question 37

Vital signs monitoring

Answer 37

Carry out in Nursing Kardex 1 How to plot in the Graphic Sheet: Place a dot in the line = even Dot in the space = odd Black ink: T, R, BP Red ink: P

Question 38

Vital signs monitoring Use ____ for PULSE RATE and the Post-operative Day (P.O.D.).

Answer 38

Red Ink

Question 39

Neuro vital signs monitoring Carry out in

Answer 39

Kardex 1

Question 40

The 1st Hospital Day is written on the

Answer 40

following day

Question 41

Oxygen saturation monitoring Transcribe in Carry out in

Answer 41

White Card Nursing Kardex 1

Question 42

Abdominal status monitoring Transcribe in Carry out in

Answer 42

White Card Nursing Kardex 1

Question 43

Abdominal girth and weight monitoring Transcribe in Carry out in

Answer 43

White Card Nursing Kardex 1

Question 44

CBG Monitoring

Answer 44

Nurses Action: Transcribe the order in the Medical Treatment Kardex 2 Make a white card Prepare and fill up CBG monitoring sheet