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PHYSICIAN IS ORDER DATE WRITTEN: TIME WRITTEN: PATIENT NAME: RM #: TO DOCTOR: Rx: Doctor's Signature, MD Date.
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FAQ
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Medication reconciliation involves a three-step process: verification (collecting an accurate medication history); clarification (ensuring that the medications and doses are appropriate); and reconciliation (documenting every single change and making sure it “squares” with all the other medication information).
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Nurses must administer medications via the route indicated in the order. If a nurse discovers an error in the order or believes the route is unsafe for a particular patient, the route must be clarified with the prescribing provider before administration.
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To be a legal order to supply or administer to a patient, a prescription on a medication chart must include: date prescribed. name and address of the patient. name and contact details of the prescriber. details of the medicine - name, form, route, dose, instructions for use.
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Call the health care provider. [If the nurse cannot understand all components of a drug order, the nurse needs to call the health care provider who wrote the order. If the health care provider is not available, the pharmacist may be able to identify which drug has been prescribed.]
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Medication reconciliation involves a three-step process: verification (collecting an accurate medication history); clarification (ensuring that the medications and doses are appropriate); and reconciliation (documenting every single change and making sure it “squares” with all the other medication information).
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Components of a Complete Order. Client name (Last and first). Medication name. Strength of medication (if required) Dosage of medication to be administered. Route of administration. Specific directions for use, including frequency of administration. Reason for administration if the medication is ordered PRN or as needed.
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Components of a Medication Order Name of the patient. Age or date of birth. Date and time of the order. Drug name. Dose, frequency, and route. Name/Signature of the prescriber. Weight of the patient to facilitate dose calculation when applicable. ... Dose calculation requirements, when applicable.
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Prescriptions generally are used for outpatient care and medication orders are used in institutional care. Medication orders are used to order medications for patients in hospitals, nursing homes, and other institutions. Medication orders also contain orders for procedures, laboratory test, and discharge instructions.
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