Drug name
01Always use generic name. Avoid brand names and never abbreviate look-alike-sound-alike drugs.
Acetaminophen
APAP / Tylenol
Step-by-step guide
How to enter a correct medication order
A medication order entered into an inpatient EMR is a legal, executable document. Pharmacy, nursing, and downstream systems will act on exactly what you wrote — not what you meant. Use this checklist for every order you sign.
01 — Required elements
Every order has eight components
Dose + units
02Numeric dose with explicit units. Use leading zero for values < 1. Never use trailing zero — a misread decimal can mean 10× overdose.
0.5 mg / 5 mg
.5 mg / 5.0 mg
Route
03PO, IV, IM, SC, SL, PR, inhaled, topical. Spell out 'subcutaneous' if your institution requires.
PO / IV
(blank) / “oral or IV”
Frequency
04Discrete frequency: Q6H, BID, daily, weekly, once, continuous infusion at rate.
Q6H
QD (looks like QID)
Indication
05Always document the clinical reason. Required for PRN orders so the right trigger is used.
Indication: pneumonia
(none)
Duration / stop
06Antibiotics, steroids, and benzos need a defined stop date or duration. Avoid open-ended orders.
x 7 days
continue indefinitely
PRN parameters
07Trigger (pain ≥ 4/10, fever ≥ 38°C), maximum dose / 24 h, what to do if ineffective.
PRN pain ≥4/10, max 3000 mg/24h
PRN
Special considerations
08Renal / hepatic adjustment, allergy check, pregnancy, weight-based for peds, drip rate for infusions.
Renal dose, CrCl 35
(no consideration)
02 — Workflow
Order entry, step by step
- 1
Verify the right patient
Confirm name + DOB + MRN in the EMR before opening the order entry screen. Two-identifier check every time.
- 2
Review allergies and active meds
Always check the allergy list and current medication list for interactions, duplicates, and contraindications.
- 3
Search by generic name
Type the generic name. Confirm formulary status and the strength your institution stocks.
- 4
Specify dose, route, frequency
Enter dose with explicit units. Choose route from the controlled list. Pick a specific frequency, not free text.
- 5
Document indication and duration
Indication is mandatory. Add a stop date for antibiotics, steroids, opioids, benzodiazepines, and anticoagulants.
- 6
Check renal/hepatic & weight
If the patient has CrCl < 60 or LFTs > 3× ULN, or is < 50 kg, verify the dose against current references.
- 7
Review the order summary
Read back the order as if you were the pharmacist. Does it answer drug-dose-route-frequency-indication-duration?
- 8
Sign and communicate
Sign the order. For urgent/stat meds, verbally notify the bedside nurse — don't assume the system will.
03 — Safety
The “Do Not Use” abbreviations (ISMP)
These shortcuts cause real harm. Spell them out.
| Don't write | Why it's dangerous | Write instead |
|---|---|---|
| U or u | Mistaken for 0 → 10× overdose | units |
| IU | Mistaken for IV or 10 | international units |
| QD / Q.D. | Mistaken for QID (four times daily) | daily |
| QOD | Mistaken for QD or QID | every other day |
| MS / MSO4 | Confused with magnesium sulfate | morphine sulfate |
| MgSO4 | Confused with morphine sulfate | magnesium sulfate |
| cc | Mistaken for U (units) | mL |
| μg | Mistaken for mg → 1000× overdose | mcg |
| .5 mg | Missed decimal → 5 mg given | 0.5 mg |
| 5.0 mg | Missed decimal → 50 mg given | 5 mg |
04 — High alert
Medications that demand extra rigor
High-alert
Insulin
- Always write 'units' — never 'u'
- Specify sliding scale parameters and basal/bolus separately
- Hold parameters for NPO / hypoglycemia
High-alert
Anticoagulants
- Weight-based dosing for heparin; specify bolus vs infusion
- Baseline labs (CBC, INR, aPTT, SCr)
- Stop date and bridging plan
High-alert
Opioids
- Specify dose ceiling and respiratory monitoring
- Naloxone availability documented
- Avoid range orders unless explicitly allowed
High-alert
Chemotherapy
- Two-prescriber verification per institution policy
- BSA / weight verified within 24h
- Pre-meds and rescue meds ordered together