Guidelines: Delineation of Medication Ordering/Preparing/Labeling
Orders for medications are written and signed by privileged
staff members with a license that allows ordering of
medications in the State where the organization is located.
Medication orders are to be written and signed by the Staff
When necessary, verbal orders, including telephone orders,
may be taken; the order must be promptly recorded in the
patient record and signed within a specified time frame as
applicable by State or Federal Law. In this organization that
time frame is 48 hours or 2 days. Verbal orders shall include
the date, time and name of Staff member and the full
signature of the staff person receiving the order; this
includes receiving of any test results via telephone. Any
verbal order or test results received by a clinical staff
member must be read back to the ordering physician or the
technician relaying results of test results to assure correct
information has been recorded. All numbers within the
verbal order will be repeated, e.g., the number 15 is read
back as '1-5', not '15'. Medication will not be administered
if the order is not
complete; a complete medication order contains the
A. Name of drug
B. Strength per dose
C. Frequency of administration
D. Indication for use when applicable
E. Method of administration
F. Date, time and signature
G. IV orders and/or orders for medical gases must
include rate of administration.
H. Whether generic or brand name is acceptable
Any medication that is ordered and there is a known 'sound a
like look a like' medication; that prescription will be
printed not written.
Standard abbreviations are utilized by the facility, as
approved by the Medical Director. However, more importantly,
there is also a list of abbreviations not to be utilized by
the organization. The 'do no use' list applies to all orders
and all medication-related documentation including
pre-printed forms. Staff who administer medications are aware of the do not
Should a medication order appear incomplete, illegible or is
unclear, the order will not be carried through and the
clinical provider writing or ordering the medication will be
contacted to clarify. This clarification will be documented.
Medication orders that involve elements, such as PRN will be
specific for what it is needed for, i.e. prn pain, prn
indigestion, etc. Should it be applicable the following
will also be specific to the situation/medication, Hold
orders, automatic stop orders, resume orders. Titrating and
tapering orders will provided a specific distinct schedule
for titrating or tapering.
Orders for compounded medications, medication related devices
(nebulizers), investigational medication, and orders for
herbal products and discharge medications will be written in
a format as described above (A-H)
The person administering any medication must be aware of the
possible untoward actions or side effects of the medication
and the name and geographic location in the facility of any
All drugs administered shall be recorded on the patient's
chart with all of the above information.
If hazardous medications are being prepared by staff, staff
uses safety materials and equipment.
Staff preparing medications use techniques to assure
accuracy, (preparing medications in a quiet area, visually
inspecting the integrity of a medication, checking the
medication label before pouring, after pouring, and as the
container/vial is put away, disposing of any medication where
an error in preparation is suspected)
Staff utilizes clean technique as appropriate as
well as preparing in a functional area which is uncluttered
The following procedures will be followed regarding
A. Once withdrawn, medication may not be returned to a
B. Medication may not be used from a container if the
label is unclear or defaced.
C. Medication from an open vial will not be used if
there is particulate matter in the vial; even though
it may not have passed the manufacturer's expiration
D. Incompatible injectable medications will be
administered at different injection sites.
All compounded IV admixtures must have the date prepared
and the diluents or additive recorded on the IV bag.
Any medication that is drawn into a syringe, and is not used
immediately; the syringe must be labeled with the drug name,
strength, amount, and expiration date.
When preparing medications for multiple specific patients the
label must also include the patient's name.
Anesthesia drug preparation and administration is the
responsibility of the anesthesia provider, unless the
surgeon is sedating the patient, then that
individual is responsible. Medications and supplies will
routinely be checked for outdates.
Approved By Governing Board