How do I draft clean doctor's orders from unclear handwritten orders?

Drafting Clean Doctor's Orders from Handwritten Orders

When transcribing unclear handwritten orders, never guess or assume—always contact the prescribing provider directly for clarification before proceeding, as illegible orders are a major source of preventable medication errors and patient harm. 1

Immediate Action Steps

• Stop and do not transcribe any order that is illegible, incomplete, or ambiguous—20% of handwritten medication orders are illegible or legible only with significant effort, and 24% are incomplete. 1
• Contact the prescribing provider immediately by phone or secure messaging to clarify all unclear elements before proceeding. 2
• Document the clarification by having the provider either rewrite the order legibly, enter it electronically, or verbally confirm all details while you document the conversation. 3

Essential Elements Required for Every Order

Every medication order must contain the following components to be considered complete and safe: 1

• Patient identification: Full name and medical record number 3
• Date and time: When the order was written (missing in 18% and 58% of orders respectively) 1
• Drug name: International non-proprietary name (generic name preferred) 3
• Dose: Specific amount with units clearly stated 1
• Route of administration: Oral, IV, subcutaneous, etc. 3
• Frequency: Specific timing (e.g., "every 8 hours" not "TID") 3
• Duration: How long the medication should continue 3
• Indication: Why the medication is being prescribed 3
• Provider signature: Legible signature or electronic authentication (78% of handwritten signatures are illegible) 1

High-Risk Situations Requiring Extra Caution

Pay particular attention when orders involve high-risk medications, as these pose the greatest danger when misinterpreted: 4

• Insulin: Never discontinue based on a single normal glucose reading; clarify exact dosing, timing, and blood glucose parameters. 5
• Anticoagulants (heparin, warfarin): Verify dose, route, and monitoring parameters. 4
• Naloxone, flumazenil, dextrose: These emergency medications are frequently mentioned in unclear orders. 4
• Potassium chloride (KCl): Should ideally not be stored in patient care areas; verify concentration and rate if ordered. 3
• Chemotherapy agents: Error rates of 4.2% with handwritten orders can cause serious harm. 6

Specific Clarification Questions to Ask

When contacting the provider, obtain clarification on: 1, 3

• Exact drug name: Spell it out if there's any ambiguity
• Precise dose and units: "mg" vs "mcg" vs "units"
• Complete route: Specify which IV line if multiple access points exist
• Exact timing: Clock times rather than abbreviations
• Stop date or duration: When should this medication end
• Special instructions: "With food," "on empty stomach," "hold for systolic BP <100"

Documentation of Clarification Process

Create a clear audit trail of the clarification: 3

• Document the date and time you contacted the provider
• Record the provider's name and contact method used
• Note exactly what was clarified
• Have the provider co-sign or electronically verify the transcribed order
• If using verbal orders, follow your institution's read-back verification protocol

Common Pitfalls to Avoid

• Never perform "blind transcription" of illegible orders hoping you've interpreted correctly—this is a form of "pseudo-practice" that compromises patient safety. 3
• Do not rely on context clues alone to fill in missing information, as prescribing errors are often multifactorial and assumptions can compound the problem. 2
• Avoid dangerous abbreviations: Do not use "U" for units, "QD" for daily, trailing zeros, or other error-prone abbreviations even if present in the original order. 3
• Do not assume continuation of home medications without explicit orders—verify each medication individually. 3

System-Level Solutions

Advocate for institutional changes to prevent this problem: 6, 7

• Computerized provider order entry (CPOE) reduces problematic orders from 30.6% to 2.2% and harmful errors from 4.2% to 0.1%. 6
• Standardized order sets with pre-printed templates reduce errors significantly when electronic systems are not available. 6
• Mandatory provider education on legible prescribing and complete order writing. 7
• Regular audits of order legibility and completeness with feedback to providers. 7

Special Considerations for Specific Patient Populations

For patients with special healthcare needs or advance directives: 3

• Verify any DNAR/AND orders are clearly documented with specific limitations detailed
• Ensure emergency information forms are available and current
• Confirm all chronic medication orders are complete and reconciled

For discharge orders: 3

• Ensure written discharge instructions are in patient-centered language
• Include specific return precautions and follow-up timing
• Verify medication reconciliation is complete and accurate