Patient Records, Medication Orders, and Labels
• Interpret medication orders and labels.
• Identify abbreviations that cannot be used for handwritten medical records.
• Identify abbreviations that can lead to medication errors.
• Utilize TJC and ISMP medication-related recommendations
• Identify forms of medications.
• Read and write time using the 24-hour clock.
• Describe the data from the order and label that must be entered in all medication calculations.
• Interpret Medication Administration Records (MARs).
• Describe medication-related nurse actions that may lead to medication errors.
Introduction
Physicians and other prescribers enter medication and treatment orders on a computer or the patient’s medical record on a page usually designated “Physician’s Order Sheet” or “Doctor’s Order Sheet.” Several abbreviations are used to write medication orders, labels, and records.
The medication orders are sent to the pharmacy. The trend has been for the pharmacy to transfer the orders to their computerized forms. In most hospitals, medications are charged to the patient and delivered to the patient’s area by the pharmacy in unit-dose (single-serving) packages labeled in metric system measurements. The medications may be stocked in a locked cabinet or in drawers of a locked medication cart until needed and restocked periodically by the pharmacy, usually every 24 hours.
The nurse must check the complete written order against the label on the medication supplied. If there is any discrepancy, the physician or pharmacist, whoever is more appropriate for the situation, must be contacted. If the amount of the dose is ordered based on the patient’s weight or the amount of drug on hand is not identical to the amount ordered, a calculation may be needed. Usually, such calculations can be performed mentally, but sometimes written mathematics or a calculator is needed.
There is potential for error in each step of the written process, including the order, the medication administration record, the supplied medication and its label, and the preparation and administration. The nurse who administers the medication is legally responsible for the medications given even if the order was wrong or the medication and/or dose supplied by the pharmacy was in error. The nurse provides the final protection for patients in the medication chain.
This chapter focuses on reading and interpreting medication dose orders, labels, and abbreviations within the context of patients’ safety. Abbreviations and measurements learned in earlier chapters are incorporated.
1. What is the difference between a trade-name product and a generic product and why must the nurse know the difference?
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2. What are some examples of drug forms?
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3. How may unit-dose packaging help prevent a medication error?
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4. What is the abbreviation for the daily medication record maintained by the nurses?
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Medication Storage and Security
Medications for institutional use are stored in locked cabinets, carts, and drawers (Figure 4-1).

Bar codes are increasingly used to reduce medication errors. The pharmacy enters the patients’ drug information, records, and medication orders into a computer. Each dose is bar-coded in the pharmacy. The nurse uses a hand-held scanner to scan the drug and the patient’s wrist bracelet (Figure 4-2). The computer checks that it is the right medication for the right patient. Unit-dose medications supplied by the pharmacy also reduce medication errors.

Controlled (scheduled) drugs such as narcotics, opiates, and some non-narcotic drugs such as tranquilizers and anti-anxiety agents, have special locked storage, dispensing, disposal, and documentation requirements because of potential risk for abuse. They are placed in schedules by the Federal Drug Administration (DEA). Schedule C I (Control I) refers to drugs at the highest risk for abuse, such as crack cocaine and heroin, Schedules C II through C V drugs, which are prescribed for medical purposes, are labeled as such, with Schedule C V having least potential for abuse. Note the C II classification for morphine on the label below.

Refer to Essential Vocabulary in this chapter and Appendix B for a list of high-alert medications.
Medication Forms and Packaging
Medications are supplied in a variety of solid and liquid forms, including granules, tablets, capsules, suppositories, and various liquid preparations. The physician’s order must specify the form of the medication. A single medication may be prepared in several forms and marketed and packaged in several single and/or multidose sizes. Multidose sizes are convenient for pharmacy and home use (Figure 4-3). At most clinical facilities, the pharmacy packages smaller single-serving-size amounts from the multidose containers to reduce medication errors (Figure 4-4).

Since medications are supplied in a variety of forms to meet patients’ needs, it is important to select the form that matches the physician’s order. This is done by matching the order to the medication label. The orders for medication forms are abbreviated. There is a trend to reduce and or eliminate abbreviations in medical records.
Solid Drug Forms
Table 4-1 lists solid medication abbreviations, terms, and forms. Since the nurse must be able to interpret the abbreviations and terms, the contents of Table 4-1 should be memorized.
TABLE 4-1
Abbreviation or Term | Description |
cap: capsule | Medication covered in hard or soft gelatin. They are supplied in various sizes. The entire contents may be sprinkled in food such as applesauce or a liquid if the physician so specifies. Capsules should never be cut or divided into partial amounts. |
caplet | Smooth, lightly coated, small oval tablet. The name is derived from capsule and tablet. It may or may not be scored. |
compound | Medication consisting of a combination of two or more drugs. Each ingredient may be available in one or more strengths. The order will specify the number of tablets. If there is more than one strength, the order will specify the strength. |
enteric-coated tablet (Always write out.) | Tablet containing potentially irritating substances and covered with a coating that delays absorption until it reaches the intestine. This protects the oral, esophageal, and gastric mucosa. Should not be crushed, cut, or chewed. Enteric should be written out to avoid misunderstanding. |
gelcap, soft-gel | Capsule cover made of a soft gelatin for ease of swallowing. |
Oral dissolving tablet (ODT) | Tablet that dissolves in the mouth and does not need to be taken with water. |
powders and granules | Pulverized fragments of solid medication, to be measured and sprinkled in a liquid or a food such as applesauce or cereal. |
scored tablet | Tablets scored with a dividing line that may be cut in half. |
supp: suppository | Medication distributed in a glycerin-based vehicle for insertion into the rectum, vagina, or urethra and absorbed systemically. |
tab: tablet | Medication combined with a powder compressed into small round and other shapes. |
ung: ointment | Medication contained within a semisolid petroleum or cream base. |
CD: controlled-dose (sustained action) | Terms reflecting the use of various processing methods to extend or delay the release and absorption of the medication. They need to be differentiated from a regular form of the same medicine. |
DS: double-strength* | A regular medication may be ordered, for example, every 4 hours. An XR version may be given only every 12 or 24 hours. Some medications, such as Celexa, are marketed in both SR and XL forms. |
LA: long-acting | |
SR: slow-release | |
XL: extra-long-acting | |
XR: extended-release |
*Does not mean long-acting or extended-release. However, a DS pill probably will be given less frequently than a “regular” counterpart.
A single medicine may be available as a tablet, a capsule, a gel cap, and an enteric-coated tablet. When there is a choice, the prescriber offers the one that is best for the patient.
Never crush gelcaps, enteric-coated or other long-acting or slow release medications. Only scored tablets should be cut.
1. How is DS different from medications marked XL, XR, CD, and LA?
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Liquid Drug Forms
Liquid drug forms are packaged in small prefilled unit-dose-serving containers and larger stock bottles, such as the containers seen for multidose home prescriptions. The liquids are supplied and administered through a variety of routes to the patient in an amount of milliliters.
Liquid drug forms are administered using specially calibrated equipment: cups; teaspoons; needles attached to tubing; syringes with needles; needle-less syringes; droppers for the mouth, eye, or ear; or tubes for the stomach and intestine. See Figures 4-5 and 4-6 for some examples of oral liquid medication equipment.


Doses of oral liquid medications such as milk of magnesia (MOM) can be supplied in small single-dose packages or larger multidose bottles. As stated in Chapter 3, 5 mL and 15 mL are the equivalents of 1 calibrated teaspoon and 1 calibrated tablespoon, respectively. The manufacturer attempts to provide the usual drug dose for the target population within those two measurements because they are reasonable volumes to swallow.
Abbreviations appear in most patients’ orders and medication records. They may be handwritten or printed. Memorize the abbreviations in Table 4-2.
TABLE 4-2
Abbreviation: Term | Form |
aq: aqueous | Medication supplied in a water-based solution |
elix: elixir | Liquid medication sweetened with alcohol, e.g., elixir terpin hydrate (ETH), a cough medicine |
emul: emulsion | A mixture of two liquids, such as oil and water, that normally do not mix |
fld: fluid | Of liquid composition |
gtt | gtt is an old abbreviation derived from Latin meaning drop. Recognize it but do not write it. Write out “drop(s).” |
mixt: mixture | Compound medicine consisting of more than one liquid medication |
sol: solution | Water-based liquid medication |
susp: suspension | Solid particles mixed in liquid that must be gently but thoroughly mixed immediately before administration; should not be shaken vigorously |
Manufacturer-supplied equipment provides precise dose measurement.
Liquid forms such as elixirs and suspensions cannot be distinguished without reading the label.

1. Which of the oral liquid drug forms contains alcohol?
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2. Which of the liquid drug forms must be gently and thoroughly mixed before administration?
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Medication Routes
Medication routes can be divided into two types:
The nurse may not substitute a different route for the one ordered. Only the prescriber can write and change the medication order.
Nonparenteral routes through which medications are delivered include the following:
Several abbreviations are used in medication orders to describe specific nonparenteral routes of administration (Table 4-3). Some of these abbreviations are derived from Latin and Greek. The abbreviations must be learned even though the trend is to write more of them out in English to avoid misinterpretation.
TABLE 4-3
Nonparenteral Medication Routes
Abbreviation or Term | Route |
Ear and eye (write out) | Right ear or eye |
Ear and eye (write out) | Left ear or eye |
Ear and eye (write out) | Both ears or eyes |
buccal (bucc) | To be dissolved in the cheek, not swallowed |
enteric (write out) | Administered through a tube or port to the small intestine |
GT | Gastrostomy tube; given through a tube or port directly to the stomach |
MDI | Metered dose inhaler |
NG (T) | Nasogastric; given through a tube inserted in the nose to the stomach |
NPO | Nothing by mouth |
PO | Given by mouth |
Rectal | Write “per rectum”; do not write “PR” |
SL, subl | Sublingual, meaning “under the tongue”; to be dissolved, not swallowed |
Top | Topical, meaning “applied to the skin” (e.g., ointments and lotions) |
Vag | Given per vagina |
Refer to pp. 102-103 for the ISMP list of error-prone abbreviations and symbols.
1. What is the difference between NPO and PO?
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2. What is the difference between the buccal and sublingual routes?
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1. What cue will help you remember that PO means “by mouth”?
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2. How will you distinguish subl and subcut?
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3. How will you distinguish GT and NGT?
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The routes listed in Table 4-4 are for parenteral, or injectable, medications. Parenteral medications are administered under the skin into soft tissue, muscle, vein, or spinal cord. Memorize the abbreviations and terms in the table.
TABLE 4-4
Abbreviation or Term | Route |
epidural | Injected into the epidural space, usually in the lumbar region |
hypo | Hypodermic; injected under the skin; refers to subcutaneous and intramuscular routes |
ID | Intradermal; given under the skin in the layer just below epidermis (e.g., skin test)* |
IM | Intramuscular, intramuscularly; given into the muscle layer, usually the gluteal muscles, the thigh, or the deltoid |
intrathecal | Given into the spinal canal |
IV | Intravenous, intravenously; given into vein |
IVPB | Intravenous piggyback; given into vein via a small container attached to an established intravenous line. |
subcut† | Subcutaneous, subcutaneously; given beneath the skin, usually into the fat layer of abdomen, upper arm, or thigh |
PN | Parenteral nutrition; nutritional feedings per intravenous line into a large vein |
*Do not confuse ID route with the word “identify.”
4. Why should the route for rectal medications be spelled out rather than abbreviated with the letter R?
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5. How will you distinguish IV, IVP, and IVPB?
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6. What is the abbreviation for the intramuscular route?
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7. What is the abbreviation for the intradermal route?
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8. What is the abbreviation for metered dose inhaler?
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9. What kind of solution is PN?
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Frequency and Times of Medication
Table 4-5 lists abbreviations for terms that denote the frequency and times of medication administration. Memorize the abbreviations in the table.
“Give with food” and “Give after meals” are usually orders for medications that irritate the gastric mucosa.
Refer to the TJC “Do Not Use” list on p. 101.
Refer to the ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations on pp. 102-103.
“Give 1 hour before meals” and “Give 2 hours after meals” are orders for medications that have reduced absorption if given with food.
1. How will you remember to distinguish the abbreviations for before and after meals?
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1. What is the error on the TJC list, Table 4-6 that can occur with abbreviations beginning with a “Q”?
TABLE 4-6
The Joint Commission Official “Do Not Use” List
Do Not Use | Potential Problem | Use Instead |
U (unit) | Mistaken for “0” (zero), the number “4” (four) or “cc” | Write “unit” |
IU (International Unit) | Mistaken for IV (intravenous) or the number 10 (ten) | Write “International Unit” |
Q.D., QD, q.d., qd (daily) | Mistaken for each other | Write “daily” |
Q.O.D., QOD, q.o.d., qod (every other day) | Period after the Q mistaken for “I” and the “O” mistaken for “I” | Write “every other day” |
Trailing zero (X.0 mg)† | Decimal point is missed | Write X mg |
Lack of leading zero (.X mg) | Write 0.X mg | |
MS | Can mean morphine sulfate or magnesium sulfate | Write “morphine sulfate” |
MSO4 and MgSO4 | Confused for one another | Write “magnesium sulfate” |
Additional Abbreviations, Acronyms and Symbols (For possible future inclusion in the Official “Do Not Use” List) | ||
Do Not Use | Potential Problem | Use Instead |
> (greater than) | Misinterpreted as the number “7” (seven) or the letter “L” | Write “greater than” |
< (less than) | Confused for one another | Write “less than” |
Abbreviations for drug names | Misinterpreted due to similar abbreviations for multiple drugs | Write drug names in full |
Apothecary units | Unfamiliar to many practitioners | Use metric units |
Confused with metric units | ||
@ | Mistaken for the number “2” (two) | Write “at” |
cc | Mistaken for U (units) when poorly written | Write “mL” or “ml” or “milliliters” (“mL” is preferred) |
μg | Mistaken for mg (milligrams) resulting in one thousand-fold overdose | Write “mcg” or “micrograms” |
*Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms.
Copyright The Joint Commission, 2010. Reprinted with permission.
†Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.
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2. What is the error that can occur with the abbreviation for International Unit?
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3. To which kind of specific orders and documentation must the TJC official “Do Not Use” list apply?
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4. What does the ISMP List, Table 4-7, recommend about writing of drug names and doses? Numerical doses and unit of measure?
TABLE 4-7
ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations
Dose Designations and Other Information | Intended Meaning | Misinterpretation | Correction |
Drug name and dose run together (especially problematic for drug names that end in “I” such as Inderal40 mg; Tegretol300 mg) | Inderal 40 mg | Mistaken as Inderal 140 mg | Place adequate space between the drug name, dose, and unit of measure |
Tegretol 300 mg | Mistaken as Tegretol 1300 mg | ||
Numerical dose and unit of measure run together (e.g., 10mg, 100mL) | 10 mg | The “m” is sometimes mistaken as a zero or two zeros, risking a 10- to 100-fold overdose | Place adequate space between the dose and unit of measure |
100 mL | |||
Abbreviations such as mg. or mL.with a period following the abbreviation | mg | The period is unnecessary and could be mistaken as the number 1 if written poorly | Use mg, mL, etc.without a terminal period |
mL | |||
Large doses without properly placed commas (e.g., 100000 units; 1000000 units) | 100,000 units | 100000 has been mistaken as 10,000 or 1,000,000; 1000000 has been mistaken as 100,000 | Use commas for dosing units at or above 1,000, or use words such as 100 “thousand” or 1 “million” to improve readability |
1,000,000 units | |||
Drug Name Abbreviations | Intended Meaning | Misinterpretation | Correction |
ARA A | vidarabine | Mistaken as cytarabine (ARA C) | Use complete drug name |
AZT | zidovudine (Retrovir) | Mistaken as azathioprine or aztreonam | Use complete drug name |
CPZ | Compazine (prochlorperazine) | Mistaken as chlorpromazine | Use complete drug name |
DPT | Demerol-Phenergan- Thorazine | Mistaken as diphtheria- pertussis-tetanus (vaccine) | Use complete drug name |
DTO | Diluted tincture of opium, or deodorized tincture of opium (Paregoric) | Mistaken as tincture of opium | Use complete drug name |
HCI | hydrochloric acid or hydrochloride | Mistaken as potassium chloride (The “H” is misinterpreted as “K”) | Use complete drug name unless expressed as a salt of a drug |
HCT | hydrocortisone | Mistaken as hydrochlorothiazide | Use complete drug name |
HCTZ | hydrochlorothiazide | Mistaken as hydrocortisone (seen as HCT250 mg) | Use complete drug name |
MgSO4* | magnesium sulfate | Mistaken as morphine sulfate | Use complete drug name |
MS, MSO4* | morphine sulfate | Mistaken as magnesium sulfate | Use complete drug name |
MTX | methotrexate | Mistaken as mitoxantrone | Use complete drug name |
PCA | procainamide | Mistaken as patient controlled analgesia | Use complete drug name |
PTU | propylthiouracil | Mistaken as mercaptopurine | Use complete drug name |
T3 | Tylenol with codeine No.3 | Mistaken as liothyronine | Use complete drug name |
TAC | triamcinolone | Mistaken as tetracaine, Adrenalin, cocaine | Use complete drug name |
TNK | TNKase | Mistaken as “TPA” | Use complete drug name |
ZnSO4 | zinc sulfate | Mistaken as morphine sulfate | Use complete drug name |
Stemmed Drug Names | Intended Meaning | Misinterpretation | Correction |
“Nitro” drip | nitroglycerin infusion | Mistaken as sodium nitroprus-side infusion | Use complete drug name |
“Norflox” | norfloxacin | Mistaken as Norflex | Use complete drug name |
“IV Vanc” | intravenous vancomycin | Mistaken as Invanz | Use complete drug name |
Symbols | Intended Meaning | Misinterpretation | Correction |
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Dram | Symbol for dram mistaken as “3” | Use the metric system |
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Minim | Symbol for minim mistaken as “mL” | Use the metric system |
x3d | For three days | Mistaken as “3 doses” | Use “for three days” |
and | Greater than and less than | Mistaken as opposite of intended; mistakenly use incorrect symbol; “ 10” mistaken as “40” | Use “greater than” or “less than” |
/(slash mark) | Separates two doses or indicates “per” | Mistaken as the number 1 (e.g., “25 units/10 units” misread as “25 units and 110” units) | Use “per” rather than a slash mark to separate doses |
@ | At | Mistaken as “2” | Use “at” |
& | And | Mistaken as “2” | Use “and” |
+ | Plus or and | Mistaken as “4” | Use “and” |
° | Hour | Mistaken as a zero (e.g., q2º seen as q 20) | Use “hr, ”“h,” or “hour” |

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