Staff Nursing

Is a modality or pattern of nursing care delivery system where in a registered

professional nurse is responsible for the administration of total nursing care.

Transcription of Doctors Order:

1. Ensure the legality of orders
a. Signed by the Physician
b. Medication order must be specific
Name of medication (Brand or Generic name)
Stock or strength
Desired dose
Route of administration
Frequency
Timing
2. Ensure that the pateints chart sheets belong to the correct patient for whom
the order was made
3. Suggestion for transcription procedures
a. Read the whole order
b. Analyze each order
c. Interpret the order

Example:
Bricany; Syrup 5ml p.o every 6hours alternate with Bricabyl 1 nebule + 1cc NSS by
USN every 6hours.
Transcribe to:

Prescription Pad
Kardex
Standing order sheet
Medication sheet
Medication cards

Trancribe to:
-

MISCELLANEOUS SHEETS:
Service slip
Request slip
Consultation or Referral sheets
Special monitoring sheet

*Doctors Order
Dr.
Knowles
Noted by: James
Curry
SN/CSA-B
June 27,
2016
*Kardex
DC 6/27/16
6/27
6/27
(Re-entry for new dates)

*Medication Sheet
DC
June 27,
2016
*Medication Cards

BACK

*Prescription Pad
Rx Amlodepine 10mg tab #7tabs

Amoxicillin (Amoxil) 500mg #9caps

DUTIES AND RESPONSIBILITIES:
1. Receiving and giving of endorsement and special reports pertaining
topatients condition and care management
2. Make rounds with outgoing shifts
3. Prioritize assessed needs and implement measures to address such needs
4. Makes cointinuous effort in implementing on-going nursing process and
subsequent nursing care plan
5. Delegates task or assignments perinent to meeting patients needs of the unit
whenever appropriate
6. Makes clinical rounds with the physician
7. Assist in the performance of therapeutic and diagnostic procedure
8. Carry out physicians order intelligently, accurately and promptly
9. Utilizes good judgement in prompt referral of patients problems beyond
mursing measures
10.Coordinates with oher health care team and other health hospital
departments in relation to implementation of patient care management
11.Assist and supervise other personnel in the performance of their tasks,
including educational needs of the student
12.Administer procedures whicj are legal and coplicated in nature including
medications, IVs, hypodermic , parenteral medications
13.Periodic on-going assessment of patient for changes in condition
14.Anticipates patients activity particularly special procedures
15.Alert to recognize activities and cirsumstances in the ward
16.Ensure accurate, concise, complete, and informative documents to provide
tools for continuity of care and to safeguard the institution as well as
professional identity of the practitioner