Department : NURSING SERVICE Policy Index: PP-BCH-NR/GNR-035-IPP-E Title: TRANSCRIBING PHYSICIANS ORDER Applies to: All Nursing Staff Effective Date: 01-01-1432 H New
B. C. H.
IPP
1. PURPOSE : 1.1To provide guidelines by which physicians orders are transcribed onto the Medical Adminis tation Record and Nursing Kardex.
3. POLICY:
3.1 All Physician orders must be legible, clear and complete. 3.2 Overriding principles for transcription.
3.2.1 Transcribe the complete order as written. 3.2.2 Transcribe legibly. 3.2.3 Transcribe the date of the order. 3.2.4 Do not transcribe unacceptable abbreviations.
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4.6 Medication Orders with specified times for administration are transcribed exactly as ordered and administered accordingly.
4.7 All medications ordered as PRN must be transcribed onto the PRN section of the Medication
Administration Record.
4.8 NGT feeding, O2 orders and all non-medication orders are transcribed to the Kardex.
Name Prepared by: Magdalena Venzuela 1.Abdulla Obeid Al-Harby Reviewed by: 2.Ehab El Husseiny Ibrahim 3.Manae Al-Belaihy Approved by: Ahmad Abdulla Al Omar
Position Nurse Supervisor Nursing Director QM Director Medical Director Nursing Director
Signature
Date
22-11-1431 H 24-11-1431 H 29-11-1431 H 29-11-1431 H 01-12-1431 H
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