Transcribing medication orders is when someone transfers a physician’s prescription order to a medication administration record, or MAR. With medication transcriptions, the transcriber must follow certain rules to ensure accuracy and compliance.
State and federal agencies are constantly looking to improve the delivery of medications to patients. In many states, the State Board of Nursing writes regulations that ensure safe, effective medication administration and transcription so that any trained employee can read the orders clearly and with full understanding.
Prescribing a Medication
When a physician prescribes medication, she has determined or diagnosed a particular problem. The transcription of the prescription is the second most important step in the medication process because any minor error could lead to trouble for the patient taking the medicine. Transcription always receives heavy scrutiny.
Only a physician or licensed practitioner can write a medication order. The transcriber must make sure it is complete, including all of the following information: the date, name of medication, how much to take, how to take it, how often, and the physician's or practitioner's signature.
The transcriber must transfer the order to an MAR exactly as the order reads and in legible writing. If other employees cannot read it, medication errors can result that can be fatal to the patient.
Order Changes/Discontinued Medications
Discontinuing or changing medications happens frequently, and with each change, the transcriber will have to adjust the MAR to reflect new orders. The transcriber must highlight the old medication indicating the doctor is no longer giving that medication. If the new order stops or discontinues a medication, the transcriber highlights the medication, noting the date and writing DC, for discontinued, in the margin or highlighted area.
You are Accountable
Medication errors due to improper transcription account for roughly half of adverse reactions in patients, which is why it is so important to transcribe medication orders correctly. The person who transcribes medication orders is accountable for any inaccuracies.