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   
following information:
    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

use abbreviations. 
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 
applicable antidote.
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 
and clean. 

The following procedures will be followed regarding 
medication preparation:
    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    
Control #250.6