POLICY/PROCEDURE

TITLE:
WRITING, TRANSCRIBING MEDICAL ORDERS,
AUTHRIZATION AND ADMINISTRATION OF
MEDICATIONS AND RECORDING
ORIGINAL DATE:
AUGUST 2004
IDENTIFICATION
NUMBER:
CL 6050 LAST REVISION DATE:
MAY 2012
NEXT REVIEW DATE:
MAY 2015
HOSPITAL(S)

ALL HMC HOSPITALS / ENTITIES
Sheet No. 1 of 10


Medication Management and Use (MMU) Quality Management Department
Regulatory & Accreditation
1.0 POLICY STATEMENT/PURPOSE:

1.1 This policy is formulated for all Hamad Medical Corporation (HMC) healthcare
providers about ordering, writing and transcribing medical orders, authorization for
medication administration, recording medication in the medical record and on the
safe and accurate administration of medications.

2.0 DEFINTIONS:

2.1 A MEDICAL ORDER An authoritative direction or instruction, issued by a
physician, in writing, or by dictation, verbally or by phone, or otherwise, a rule or a
course of action to be implemented by other health care providers, patient, family,
legal guardians, or significant others, in the treatment, plan of care or service, for the
patient. This may include prescription of medications, diagnostic tests, etc.

2.2 TRANSCRIBING MEDICAL ORDERS -- To copy, write over again, transfer or
translate Information from the physicians medical order or instructions on to the
patients medical records for further medical or nursing action e.g. issuing of the
medication by pharmacy department and administration of the medication to the
patient.

2.3 AUTHORIZATION FOR MEDICATION ADMINISTRATION -- The process of giving
certain health care providers legal and professional permission to provide a patient
with a substance prescribed and intended for the diagnosis, treatment, or prevention
of a medical illness or condition.

2.4 MEDICATION ADMINISTRATION -- The practice of administering medications,
which involves providing the patient with a substance prescribed and intended for
the diagnosis, treatment, or prevention of a medical illness or condition.

2.5 TIME CRITICAL SCHEDULED MEDICATION Are those where early or delayed
administration of maintenance doses of greater than 30 minutes before or after
scheduled dose may cause harm or result in substantial sub-optimal therapy or
pharmacological effect.






POLICY/PROCEDURE

TITLE:
WRITING, TRANSCRIBING MEDICAL ORDERS,
AUTHRIZATION AND ADMINISTRATION OF
MEDICATIONS AND RECORDING
ORIGINAL DATE:
AUGUST 2004
IDENTIFICATION
NUMBER:
CL 6050 LAST REVISION DATE:
MAY 2012
NEXT REVIEW DATE:
MAY 2015
HOSPITAL(S)

ALL HMC HOSPITALS / ENTITIES
Sheet No. 2 of 10


Medication Management and Use (MMU) Quality Management Department
Regulatory & Accreditation

3.0 PROCEDURE/PROCESS:

3.1 All medical orders shall be written on a physician order sheet. These include but are
not limited to diagnostic, therapeutic, treatment and palliative care as well as
referrals to other disciplines and healthcare facilities, and orders for medications.

3.2 Medication orders shall be written on the Physicians Prescription Sheet or through
Computer Physician Order Entry (CPOE).

3.3 Orders shall be accurately transcribed by qualified health care providers.

3.4 Medications administered by HMC qualified health care providers shall be written on
the designated forms, including the date, time, signatures and stamp.

3.5 Writing Medical Orders

3.5.1 Only qualified physicians should write medical orders at HMC.

3.5.2 Only orders written on designated order sheets should be considered valid
to be carried out by health care providers.

3.6 Physicians Prescription Sheet should be used for medications order only and
should be completed only by a privileged physician.

3.6.1 The bottom duplicate copy should serve as the medication prescription that
should be filled by the Pharmacy (See Prescribing of Medications, Policy
No. CL 6048).

3.7 Physician Order Sheet should be used for all orders other than medication orders,
and should be completed only by privileged Physicians.

3.8 Transcription of Medication Orders

3.8.1 The staff nurse who transcribes the medication order should complete the
following:




POLICY/PROCEDURE

TITLE:
WRITING, TRANSCRIBING MEDICAL ORDERS,
AUTHRIZATION AND ADMINISTRATION OF
MEDICATIONS AND RECORDING
ORIGINAL DATE:
AUGUST 2004
IDENTIFICATION
NUMBER:
CL 6050 LAST REVISION DATE:
MAY 2012
NEXT REVIEW DATE:
MAY 2015
HOSPITAL(S)

ALL HMC HOSPITALS / ENTITIES
Sheet No. 3 of 10


Medication Management and Use (MMU) Quality Management Department
Regulatory & Accreditation

3.8.1.1 Order date.
3.8.1.2 Medication.
3.8.1.3 Dosage and Frequency.
3.8.1.4 Route.
3.8.1.5 Time.
3.8.1.6 Commencement date, if applicable.
3.8.1.7 Discontinuation date, if applicable.

3.8.2 Any change in the medication dose, route or frequency should be written as
a new prescription. These changes should then be transcribed as a new
order. Order date should indicate the date when the new prescription is
written.

3.8.3 Transcriptions of all medication orders should require a verification of the
accuracy of the transcribed order by a second nurse and it should be
documented on the Medication Administration Record (MAR).

3.9 Recording Medication Administration

3.9.1 The Medication Administration Record should be utilized in all inpatient
units, Emergency Department (Short Stay Unit), Day Care Unit and
Radiology Department for documenting medications administered by all
routes.

3.9.2 The Intensive Care and Intermediate Care Units should utilize the Intensive
Care or Intermediate Care Flow Sheet for documenting the full details of
medications administered by intravenous infusions.

3.9.3 Procedural areas and the peri-operative areas should document medication
administration on their respective Medication Administration Records or
Flow Sheets.

3.9.4 All health care providers authorized to administer medications should
document the medication administration on the designated administration
recording form immediately after administration with date and time.




POLICY/PROCEDURE

TITLE:
WRITING, TRANSCRIBING MEDICAL ORDERS,
AUTHRIZATION AND ADMINISTRATION OF
MEDICATIONS AND RECORDING
ORIGINAL DATE:
AUGUST 2004
IDENTIFICATION
NUMBER:
CL 6050 LAST REVISION DATE:
MAY 2012
NEXT REVIEW DATE:
MAY 2015
HOSPITAL(S)

ALL HMC HOSPITALS / ENTITIES
Sheet No. 4 of 10


Medication Management and Use (MMU) Quality Management Department
Regulatory & Accreditation

3.10 Authorization for Medication Administration

3.10.1 At Hamad Medical Corporation, medications shall be administered to a
patient by the following staff:

3.10.1.1 Staff Nurses with a validated competency.

3.10.1.2 Anesthesiologist, Dentists and other Physicians who are
licensed and have clinical privileges at Hamad Medical
Corporation.

3.10.1.3 Respiratory Therapist (Respiratory Treatments only), Physical
Therapist, Radiology Technologist and Electro-Encephalogram
(EEG) Technicians shall administer medication within the scope
of their practice, Anesthesia Technicians and/or Technologists
administer medications under the supervision of the
anesthesiologist.

3.10.2 Nursing students should administer oral, intramuscular, subcutaneous and
topical use medications only under the direct supervision of the Preceptor or
Clinical Instructor.

3.10.3 The Clinical Instructor or Preceptor should be a staff nurse who assumes
responsibility for the nursing practice of the student.

3.10.4 The Medication Administration Record (MAR) should be countersigned by
the Preceptor.

3.11 Medication Administration

3.11.1 All medication administration by any route shall be safely and correctly
performed by authorized HMC staff consistent with the seven rights of
medication administration:

3.11.1.1 Right patient.




POLICY/PROCEDURE

TITLE:
WRITING, TRANSCRIBING MEDICAL ORDERS,
AUTHRIZATION AND ADMINISTRATION OF
MEDICATIONS AND RECORDING
ORIGINAL DATE:
AUGUST 2004
IDENTIFICATION
NUMBER:
CL 6050 LAST REVISION DATE:
MAY 2012
NEXT REVIEW DATE:
MAY 2015
HOSPITAL(S)

ALL HMC HOSPITALS / ENTITIES
Sheet No. 5 of 10


Medication Management and Use (MMU) Quality Management Department
Regulatory & Accreditation
3.11.1.2 Right medications.
3.11.1.3 Right dose.
3.11.1.4 Right route.
3.11.1.5 Right time.
3.11.1.6 Patients right to refuse.
3.11.1.7 Right to patient and family education.

3.11.2 All HMC staff administering medications, including Physicians, shall follow
proper procedures as described in this Policy.

3.11.3 Only medications prescribed for the patient based on clinical necessity shall
be administered.

3.11.4 All medications administered to patients shall be recorded in their
Medication Administration Record (MAR) or appropriate flow sheet.

3.11.5 The nurse shall have the right and responsibility to question and to refuse to
carry out the order, until clarified, in the following circumstances:

3.11.5.1 Contraindicated due to drug incompatibility.
3.11.5.2 Inappropriate to the patients condition.
3.11.5.3 Known allergy to the medication.
3.11.5.4 Inappropriate for age and weight.
3.11.5.5 Illegible or any part of the Physicians order is unclear or a
concern; e.g., dosage, route.

3.11.6 A medication order transcription shall clearly indicate the following:

3.11.6.1 The date and time the order was written.
3.11.6.2 The name of the drug in generic or as prescribed.
3.11.6.3 The dose of the drug.
3.11.6.4 The route.
3.11.6.5 The frequency of the doses.
3.11.6.6 The medication discontinuation date.
3.11.6.7 The initials of the transcribing nurse.
3.11.6.8 The initials of the witnessing nurse.




POLICY/PROCEDURE

TITLE:
WRITING, TRANSCRIBING MEDICAL ORDERS,
AUTHRIZATION AND ADMINISTRATION OF
MEDICATIONS AND RECORDING
ORIGINAL DATE:
AUGUST 2004
IDENTIFICATION
NUMBER:
CL 6050 LAST REVISION DATE:
MAY 2012
NEXT REVIEW DATE:
MAY 2015
HOSPITAL(S)

ALL HMC HOSPITALS / ENTITIES
Sheet No. 6 of 10


Medication Management and Use (MMU) Quality Management Department
Regulatory & Accreditation

3.11.7 Nurses shall never administer medications via the following routes or
methods:

3.11.7.1 Intra-cardiac.
3.11.7.2 Intra-pericardial.
3.11.7.3 Intraosseous.
3.11.7.4 Intrathecal.
3.11.7.5 Intraarticular.

3.11.8 A history of medication response, allergies, sensitivities and any substance
abuse should be correctly assessed and recorded by the Physician or nurse
doing the initial assessment process or history and physical examination.

3.11.9 Patients/family or caregivers and next of kin should be educated about
medications they are receiving (Refer to Patient and Family Education,
Policy No. CL 6090).

3.11.10 Patients should be identified prior to drug administration using two identifiers
(Refer to Patient Identification, Policy No. CL 7026).

3.11.11 All medications should be properly labeled (Refer to Dispensing of
Medication, Policy No. CL 6049).

3.11.11.1 Nurses should not re-label any medication.

3.11.12 A valid medication order should be written in English and should be clear
(Refer to Prescribing of Medication, Policy No. CL 6048).

3.11.13 The health care providers administering medications should observe the
patient taking and/or swallowing the drug.

3.11.14 Administered medications must be recorded by the person who administers
the medication and signed by the witness if applicable (Refer to Narcotics
and Controlled Drugs Administration, Storage Maintenance and
Accountability, Policy No. CL 6053).




POLICY/PROCEDURE

TITLE:
WRITING, TRANSCRIBING MEDICAL ORDERS,
AUTHRIZATION AND ADMINISTRATION OF
MEDICATIONS AND RECORDING
ORIGINAL DATE:
AUGUST 2004
IDENTIFICATION
NUMBER:
CL 6050 LAST REVISION DATE:
MAY 2012
NEXT REVIEW DATE:
MAY 2015
HOSPITAL(S)

ALL HMC HOSPITALS / ENTITIES
Sheet No. 7 of 10


Medication Management and Use (MMU) Quality Management Department
Regulatory & Accreditation

3.11.15 The Standard Medication Timing as recommended by the Pharmacy
Department should be followed unless specified by the Physician.

3.11.15.1 If the order is written between the standard medication timing,
the prescriber should clearly specify the initial dose timing and
the subsequent dose.


MEDICATION ADMINISTRATION SCHEDULE

Once Daily 0800 Hours or as prescribed by the
Physician
Twice Daily

0800 Hours and 2000 Hours
Three Times Daily 0800 Hours 1300 Hours 2000 Hours
Every 8 Hours

0600 Hours 1400 Hours 2200 Hours
Four Times Daily


0800 Hours 1200 Hours
1800 Hours 2200 Hours

Every 6 Hours



0600 Hours 1200 Hours
1800 Hours 2400 Hours

Every 4 Hours 6 times a day
0800 Hours 1200 Hours
1600 Hours 2000 Hours
2400 Hours 0400 Hours
Every 12 Hours

0600 Hours 1800 Hours

At bedtime 2000 Hours or 2100 Hours







POLICY/PROCEDURE

TITLE:
WRITING, TRANSCRIBING MEDICAL ORDERS,
AUTHRIZATION AND ADMINISTRATION OF
MEDICATIONS AND RECORDING
ORIGINAL DATE:
AUGUST 2004
IDENTIFICATION
NUMBER:
CL 6050 LAST REVISION DATE:
MAY 2012
NEXT REVIEW DATE:
MAY 2015
HOSPITAL(S)

ALL HMC HOSPITALS / ENTITIES
Sheet No. 8 of 10


Medication Management and Use (MMU) Quality Management Department
Regulatory & Accreditation

3.11.16 Scheduled Medication Administration Time Frame: Scheduled
Medications might be given within one hour (1 hour) before or after the
scheduled time, with the following exceptions:

3.11.16.1 Stat orders.
3.11.16.2 First doses and loading doses.
3.11.16.3 One -time doses.
3.11.16.4 Preoperative drugs.
3.11.16.5 On call doses (e.g., pre-procedure sedation).
3.11.16.6 Time-sequenced or concomitant medications (e.g.
chemotherapy and rescue agents, n-acetaylcysteine and
iodinated contrast media).
3.11.16.7 Drugs administered at specific times to ensure accurate
peak/trough/serum drug levels.
3.11.16.8 Ante and post cibum medication (before and after meals).
3.11.16.9 Surgical Prophylactic Antibiotics should be given one hour of
induction of anesthesia.
3.11.16.10 Febrile Neutropenia patients order is considered as stat order
even if not specified.
3.11.16.11 PRN medications.
3.11.16.12 Time Critical Scheduled Medications (Refer to individual
hospitals list).
3.11.16.13 If administration time specified by the prescriber.

3.11.17 Medications prepared in clinical areas should not be stored in a syringe to
be administered at a later time or date. This excludes procedures under
moderate sedation when a top-up dose may be required (Refer to Moderate
Sedation, Policy No. CL 6029).

3.11.18 The appropriate time to administer oral medications after an NPO (Nil Per
Orum) order should be specified by the Physician.

3.11.19 Intravenous medications administered intermittently via capped vascular
access ports should be flushed with 3 to 6 ml of compatible IV fluid or
heparin lock before and after medication administration.




POLICY/PROCEDURE

TITLE:
WRITING, TRANSCRIBING MEDICAL ORDERS,
AUTHRIZATION AND ADMINISTRATION OF
MEDICATIONS AND RECORDING
ORIGINAL DATE:
AUGUST 2004
IDENTIFICATION
NUMBER:
CL 6050 LAST REVISION DATE:
MAY 2012
NEXT REVIEW DATE:
MAY 2015
HOSPITAL(S)

ALL HMC HOSPITALS / ENTITIES
Sheet No. 9 of 10


Medication Management and Use (MMU) Quality Management Department
Regulatory & Accreditation

3.11.20 Continuous intravenous (IV) medication administration requires special
assessment, monitoring and interpretations.

3.11.21 Intravenous medications should be administered by infusion.

3.11.22 Medications such as IV push through cannula should be performed only by
a physician, competent nurse or a competent paramedical staff.

3.11.23 Midnight audit of the Medication Administration Record should be conducted
by the assigned nurse on the night shift for all patients against the original
top copy of the prescription form for the previous 24 hours. This audit
should be noted and signed by the nurse on the top copy of the prescription
form.

3.11.24 Moderate sedation should be administered by a nurse certified in Immediate
Life Support (ILS), as per Moderate Sedation Policy No. CL 6029.

3.11.25 Nurses or other health care providers should not administer any
experimental or investigational medication unless approved by Research
Committee.

3.11.26 If a patient refuses to take a prescribed medication or if the health care
provider omits to administer a medication, the following actions should be
taken:

3.11.26.1 The incident should be documented.
3.11.26.2 The Physician should be notified.
3.11.26.3 The nurse should complete an Occurrence, Variance and
Accident (OVA) report if the outcome of 3.11.26 above, is likely
to have serious potential or actual consequence to the patient.




POLICY/PROCEDURE

TITLE:
WRITING, TRANSCRIBING MEDICAL ORDERS,
AUTHRIZATION AND ADMINISTRATION OF
MEDICATIONS AND RECORDING
ORIGINAL DATE:
AUGUST 2004
IDENTIFICATION
NUMBER:
CL 6050 LAST REVISION DATE:
MAY 2012
NEXT REVIEW DATE:
MAY 2015
HOSPITAL(S)

ALL HMC HOSPITALS / ENTITIES
Sheet No. 10 of 10


Medication Management and Use (MMU) Quality Management Department
Regulatory & Accreditation

3.11.27 Medication Administration to a Discharged Patient

3.11.27.1 If a patient is discharged but remains in the patient care area,
medications should be given as ordered until the patient
physically leaves the unit, or the Physician writes an order
indicating otherwise.

4.0 DOCUMENTATION:

4.1 Documentation as per Hamad Medical Corporation Guidelines.

5.0 REFERENCES:

5.1 Joint Commission International Accreditation Standards for Hospitals, 4th Edition.
Medication Management and Use Chapter, Standards MMU 6, MMU 6.1, MMU 6.2

5.2 Medication Administration. (2003). American Academy of Pediatrics, Retrieved
December 12, 2008, from http://nrc.uchsc.edu/SPINOFF/MED/Medication.pdf.

5.3 ISMP Guidelines for timely medication administration :response to the CMS (30
minutes rule) www.ismp.org./newsletters/acutecare/articles/20110113.asp

6.0 ATTACHMENTS: Not Applicable.