MEDICAL SERVICES 23-

02-008

POLICY ON WRITING COMPLETE MEDICATION ORDERS

POLICY STATEMENT.

The Division of Veterans Healthcare Services (DVHS) requires each of the New Jersey Veterans Memorial
Homes (VMH) to clarify requirements and ensure that all physicians and/or advanced practice nurses
write medication orders that are clear, complete and non-ambiguous. Verbal or telephone orders
obtained by nurses shall also comply with the requirements for writing complete medication orders.

PURPOSE.

The purpose of this policy is to support safe medication ordering practices in each New Jersey Veterans
Memorial Home.

PROCEDURE.

A complete, written medication order shall always include the following components:

Date and Time the order was written;

Medication Name (Generic or Brand is acceptable);

Dosage Strength;

Dosage Form (only if not a solid; e.g. syrup, solution, concentrate, etc.);

Route of Administration (by mouth; IV; injection; eye drops; G-tube; etc.);

Frequency of Administration;

Duration of Therapy;

Indication(s) for Use (all prn [as needed] medications are required to have an indication or reason for
use);

Signature of Physician or Advanced Practice Nurse

When the physician or advanced practice nurse increases the dose or otherwise changes an existing
medication order, the prior medication order MUST be discontinued (D/C’d) in writing entirely, and a
new, complete medication order (as above) must be written.

To avoid confusion, physicians or advanced practice nurses are asked not to make hand-written changes
to orders on the pre-printed monthly physician order sheets (POS).

If an error is noted on the newest pre-printed monthly physician order sheet (POS), the physician/APN
may cross out and correct the error (this usually involves writing a complete, new order), “date and
time” this correction, and then bring it to the attention of the nurse and/or the pharmacist for further
action.
Physicians and advanced practice nurses shall write out medication orders completely, and avoid the use
of unapproved abbreviations. Only abbreviations discussed and accepted in the VMH shall be used when
writing medication orders. Please refer to the “Institute for Safe Medication Practices (ISMP)’s List of
Error-Prone Abbreviations, Symbols, and Dose Designations”, found here as 23-02-008A.

To avoid medication errors, the spelling-out of words that are often abbreviated is also recommended,
for example:

Write “units”, not U or u;

Write “daily”, not od (once daily) or qd / QD;

Write “every other day”, not qod or QOD;

Write full drug names (e.g. Penicillin, not PCN)

Use “greater than” or “less than” instead of > or <

If decimal points are necessary, use a “leading zero” before a decimal point (e.g. write 0.5 mg not .5 mg).
Never use a “trailing zero” after a decimal point (e.g. write 5 mg not 5.0 mg).

Please use only the metric system. Please do not use # tablespoons (T. or tbs. or tbsp.), teaspoons (t. or
tsp.), vials, drams (ʒ), minims (♍), etc.

The following are not acceptable orders:

“Blanket Orders” – such as “continue previous orders”; or

“Range Orders” – such as “one or two tablets every 4-6 hours”, unless the VMH has a clear, internal
policy in this regard.

All “prn” orders shall have clear instructions and parameters for use.

Physicians and APNs shall immediately inform nurses of emergency or STAT orders so that these orders
can be transcribed and sent to the pharmacy or dispensed from the back-up supply as soon as written.

Nurses who transcribe telephone orders (TO) or verbal orders (VO) must write a complete medication
order (as above), note the order as either TO or VO, then have these orders signed by the physician or
APN on the next day that they come to the VMH. Physicians or APNs must sign the order, then write the
date and time that they signed it.

Physicians or APNs with poor handwriting shall be counseled by the Medical Director, and shall be asked
to print their orders so these orders can be read by the nursing and pharmacy staff.