Chapter 13: Processing

Medication Orders
and Prescriptions

Inpatient Pharmacies
Receiving Medication Orders
hand-delivered
mechanical method
fax transmission or pneumatic tube
Computer physician order entry, or CPOE
orders verified by pharmacisst
Telephone orders
by prescriber or an intermediary
legal restrictions

Upon Receipt
2 steps
review order for clarity & completeness
prioritize the order

Ideal Medication Order

Patient name
Hospital identification

#
Room/bed location
Generic drug name
Brand drug name*
Route of administration
Dosage form
Dose/strength
Frequency & duration

Rate & time

Indication
Other instructions
Prescribers signature
Printed name if

needed
Credentials
Pager number
Date & time of order

Prioritization
PATIENT DISCOMFORT
initial treatment of pain, fever, or nausea &
vomiting are generally high priority
Urgent orders are filled first
Evaluate by analyzing:
route
time of administration
type of drug
intended use of drug
patient-specific circumstances

Order Start Times

STAT immediately- an urgent need
Now or ASAP
start today or start this morning
Has 1st dose of medication been given? (ER)
Standard amount of time to process & deliver order
typical turnaround times in hospital
15 minutes for STAT order
1 hour for a routine order

Technicians use critical thinking skills to prioritize

orders

Processing Medication
Orders
Identify patient
Compare order with patients existing

medication
Order entry steps
choose correct medication from database
identifying administration schedule
enter any special instructions

Medication must be selected, prepared or

compounded, checked, dispensed for use

Patient Profile
Patient name
Identification numbers
Date of birth/age
Sex
Height and weight
Lab values
Admitting/2nd

diagnoses
Room & bed number

Names of admitting &

consulting physicians
Allergies
Medication history
Special considerations
Clinical commentstherapeutic
monitoring,
counseling notes

Selecting Drug Product

Drug may be ordered by generic or brand

name
Abbreviations often used
Lists of abbreviations that cannot be used
Look-alike & sound-alike drug strategies
store in separate locations
additional labeling
tall man letters (example: buPROPion

busPIRone)

Drug Selection
Mnemonic is code, associated with

medication
Ampicillin 250 mg
mnemonic, or drug code, amp250,
choices:

amp250c ampicillin 250 mg capsule

amp250s ampicillin 250 mg/5 mL oral suspension
amp250i ampicillin 250 mg injection

Order Processing
Labels generated upon order entry
IV label format different from unit dose tablet
Form of medication
pediatric
meds through tubes (nasogastric tubes or

gastric tubes)

Formulary considerations

Order Processing
Pharmacist input
consult pharmacist if any warnings appear
Computer warnings:
interactions
duplications
allergies
dosage range
diluent choices

may be standardized as defaults in computer system

Final step-pharmacist verification of all orders

Medication Administration
Times

Administration time impacts:

drug efficacy
diagnostic laboratory testing
Pharmacokinetic studies using administration
time in relation to lab test time to determine
drug dose recommendation
Full stomach or empty stomach
Standard medication administration times

Standard Administration
Times
daily = 0900 (9 a.m.),
bid = 0900 and 1700 (5 p.m.)
q8h=every 8 hours = 0600 (6 a.m.), 1400 (2

p.m.), and 2200 (10 p.m.)

Warfarin 1700 to allow time to review lab
results
Standardized schedules of drug
administration
based on therapeutic issues, nursing, pharmacy

MAR
Medication administration record
Part of patients medical record
Nurse documents when medication administered
Standardized times appear as default entries on

MAR
Default times may differ on some specialized units
daily may default to 0900
physical rehabilitation unit

might require daily administration to occur at 0800

Scheduling
Considerations
Must be aware of exceptions
Pharmacists must consider other medications
ciprofloxacin & calcium carbonate must be spaced
day or days of the week
important to coordinate with patients home
schedule
every-other-day orders

avoid advising caregiver to give medication on odd

days or even days, because depending on number of
days in month, every other day will change with
respect to odd/even

Information System
Physicians orders are input into patient profile

in pharmacy information system

Information used to generate:
MARs
medication profiles
fill lists (for pharmacy use)
labels for medications to be issued to patient

care areas

MARs may be either paper or electronic

(eMAR)

Special Instructions
Pharmacy instructions
notes between pharmacist/technician
clinical notes
Nursing instructions
storage information
administration instructions
physician-specified parameters
displayed on MAR & medication label

Sample Inpatient Order

Entry
Enter patients name/account number-verify pt
Compare order to patient profile in detail
Enter drug
Verify dose
Enter administration schedule
Enter any comments in clinical comments field
Verify prescriber name
Fill & label medication

Filling, Labeling,
Checking
Send enough doses to last to next scheduled
delivery
24-hour cart fill system common

Review label carefully

against order
against product
Medication order is filled
Pharmacist checks-legally required in most

cases
Technology-order images archived

Special Considerations
Charge-Only & No-Charge Entries
Pharmacist protocols
Diagnostic preparation orders
Computer physician order entry
Automated dispensing technology
Centralized dispensing automation
Decentralized automation

Outpatient Pharmacies
Receiving Prescriptions
presented in person
telephoned in from prescribers office
facsimile
electronic transmission
Refill requests
internet
phone

manual-uses person
automated system

Payer Information
Establish:
primary payer for prescription
patients portion of reimbursement

(copayment)
drug formulary

Electronic claims adjudication

Prescription may be held until information

gathered

Clarity & Completeness

Patient name
Patient home address
Date written
Drug info
name
strength
dose
Directions
route

Frequency & duration

Quantity to be

dispensed
Number of refills
Substitution (DAW)
Signature/credentials
DEA # if required
Prescribers info
name, address, phone
indication (not

required, but
recommended)

Dispense as Written
(DAW)
DAW= brand name drug written must be
dispensed
Some states require phrase Do Not
Substitute (DNS)
Must consider state law & pharmacy policy
Preprinted areas-prescriber signs to designate

DAW or generic substitution acceptable ok

in some states

DAW codes
0
1
2
3
4
5
6
7

= No product selection indicated

= Substitution not allowed by provider
= Substitution allowed- patient requested product
= Substitution allowed- pharmacist selected product
= Substitution allowed- generic drug not in stock
= Substitution allowed- brand drug dispensed as generic
= Override
= Substitution not allowed- brand drug mandated by
law
8 = Substitution allowed- generic drug not available in
marketplace
9 = Other

Forgeries
Screen prescriptions for controlled substances
May be fairly easy to identify
erasure or overwriting of strength or dispensing

quantity of drug (changing 3 to 8)

More subtle
theft of preprinted prescription pads
legitimate-looking prescriptions
telephoned in to pharmacy

Other Considerations
Legibility problems & interpreting

abbreviations
Patient notification if
contacting prescriber
medication is not in stock

Prioritization
order in which presented to pharmacy
common-sense judgment

Patient Profile
Patients name/identification number
Date of birth/age
Home address/telephone numbers
Allergies
Principal diagnoses
Primary healthcare providers
Third-party payer(s)/other billing information
Over-the-counter medication/herbal supplements
Prescription & refill history
Patient preferences

Prescription Entry
Appropriate drug product selection
mnemonic
alphabetical listing
National Drug Code (NDC) number
Directions for use
Fill quantity
Initials of pharmacist checking prescription
Number of refills authorized

Primary Prescription
Label
(information may vary by
Patients name
Date the prescription is being filled (or refilled)
state)
Prescribers name
Sequential prescription number
Name/strength/manufacture
Quantity dispensed
Directions for use
Number of refills remaining/associated refill period
Expiration date
Physical description of med if required by state law

Instructions for Use

Administration directions (Take, Insert,

Apply)
Number of units constituting one dose/dosage
form
Route of administration
Frequency
Duration if applicable (for 10 days, until
finished)
Indication if applicable (ex: for pain or for
blood pressure)

Outpatient Prescription
Process
Enter patients medical record number or name
Enter or verify existing third-party billing

information.
Compare order to patient profile in detail
Enter drug
Enter label direction mnemonic
Enter comments
Enter prescribers name
Enter amount to dispense/refill information
Fill & label the prescription