how to write orders..

[nofear]

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I guess its a dumb question and i am sorry if i offended anyone but i just started in patient and there are certain things I dont know what how to write orders for ...for example magnisum sulfate 2g in 100cc over 2 hrs (or something like that) but is there a web site or a book that tells you if someone tells you to write orders for X this is the way you write it...
thanks

 

[EM_Rebuilder]

I guess its a dumb question and i am sorry if i offended anyone but i just started in patient and there are certain things I dont know what how to write orders for ...for example magnisum sulfate 2g in 100cc over 2 hrs (or something like that) but is there a web site or a book that tells you if someone tells you to write orders for X this is the way you write it...
thanks

Buy or get from a durg rep, a Pharmacopeia (spelling). Thats is the godsend as far as drug dosing goes. Nursing staff is often helpful on dosing and such; espically in the Emergency Department and ICUs.

If you are unsure on the number of days of something for a script, use something like UpToDate, EMedicine.com, an upper level, nurse, etc... it usually has good reference. Also, Sanfords, is the gold standard for antibiotics. I keep that around to see which Abx I should go with, dosage for the bugs, and how long...

Good luck and hope that helps from a one month+ intern...

 

[jennyboo]

The basic format is

[DRUGNAME] [AMOUNT] [UNIT] [ROUTE] [FREQUENCY]

so

magnesium sulfate 2 grams IV x1 (for a one time dose, and the nurses at our hospital already knew it comes pre-mixed so we didn't need to specify how much fluid it should be in, and they already knew how fast to run it)

For a regularly scheduled medication such as a beta blocker,

metoprolol 25 mg PO bid
atenolol 50 mg PO daily

Potassium is in millequivalents, so for a one-time dose,

potassium chloride 20 mEq PO x1 or potassium chloride 20 mEq IV x1

 

[Tired]

I guess its a dumb question and i am sorry if i offended anyone but i just started in patient and there are certain things I dont know what how to write orders for ...for example magnisum sulfate 2g in 100cc over 2 hrs (or something like that) but is there a web site or a book that tells you if someone tells you to write orders for X this is the way you write it...
thanks

This is how you do it.

1) Write the order however you like
2) The nurse or ward clerk pages you to tell you that you wrote it wrong
3) You go up there and say, "What did I do wrong?"
4) They tell you.
5) You change it

Easy as pie, I do it all the time.

 

[nofear]

thanks guys, i will follow the advice.

 

[Faebinder]

This is how you do it.

1) Write the order however you like
2) The nurse or ward clerk pages you to tell you that you wrote it wrong
3) You go up there and say, "What did I do wrong?"
4) They tell you.
5) You change it

Easy as pie, I do it all the time.

👍 Leave your pager on the sheet so they can page you. Soon you learn what to write so that they dont need to page you.

 

[Dr JPH]

When in doubt, keep it simple. The people entering the orders are often unit clerks with little or no medical training. I get paged all the time to clarify orders that I wrote because they werent written "how everyone else writes them."

Each hospital has a unique way of doing things.

One hospital I go to you need to order a BMP as an "ASTRA" because thats how it was written in the good old days...the machine used to run the sample was called an ASTRA machine or made by a company called ASTRA...some nonsense like that.

If you write things other ways you confuse the unit clerks.

Like the page I got the other night:

Clerk: "You didnt put a reason for the CT scan in your order"
Me: "Pancreatitis"
Clerk: "I cant put that. You cant use pancreatitis as a reason for a scan."
Me: "Why not?"
Clerk: "You cant see pancreatitis on a CT scan."
Me: "Really?"
Clerk: "Yep."
Me: "Abdominal pain." <click>

🙄

 

[fab4fan]

Sometimes the computer system asks you for an ICD-9 code or some other specification, or it will reject the entry or make the pt. pay for the test. That's why you get asked for specifics.

 

[Tired]

Back in my civilian school, we were constantly whacked for writing "r/o _____ " as a reason for scans. Apparently (so we were told) rule-out is not an adequate justification, you had to actually specify a presenting symptom or diagnosis.

Of course, in the military, "because I said so" will suffice. 😀

 

[gutonc]

Back in my civilian school, we were constantly whacked for writing "r/o _____ " as a reason for scans. Apparently (so we were told) rule-out is not an adequate justification, you had to actually specify a presenting symptom or diagnosis.

True (and annoying). You can't bill for ruling something out. You can bill for "abdominal pain" however. It is kosher to put "LLQ abd pain, r/o diverticulitis" though, as long as there's something in there to bill for. Plus this way gives the radiologist something to go on when reading the scan.