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Prescription documentation (Principles of good prescribing (National and…
Prescription documentation
Introduction
Use approved abbreviations only (g, mg),
all others written in full
Use generic name, except where known
difference in clinical effect between brands
Extra legal requirements for controlled drugs
e.g. formulation needs to be stated
If prescribing unlicenced/off label, ensure no
suitable licenced, on-label alternative first
Legally and legibily
National and local (Trust) guidance
Prescribe within own limits and expertise
Prescription
documentation
Prescribers
Dieticians
Nurses/midwives
Doctors and dentists plus trained non-medical prescribers (NMP),
supplementary prescribers (SP) or independent prescribers (IP)
Pharmacists
Physiotherapists
Podiatrists
Radiographers
Paramedics
Primary care
prescriptions
Green (FP10NC /HNC /SS)
GPs, hospital, IPs and SPs
Lilac (FP10 PN/ SP)
Nurse IP and SP
Yellow (FP10D)
Dentists
Blue (FP10MDA)
Drugs of misuse for opioid dependence
e.g. methadone
Pink (FP10PCDNC/ SS
Private (non-NHS) prescriptions
Sector 2/3 controlled drugs
Human Medicines
Regulations (2012)
Manufacture, import, distribution, sale, supply,
labelling, advertising, monitoring
Regulatory bodies e.g. GMC also have guidance
(
Good practice in prescribing medicines and devices 2013
)
Legislation for authorising medicines
for human use in the UK
Patient-specific
directions (PSDs)
Royal Pharmaceutical Society definition
Written instructions from a doctor, dentist or other IP for a medicine to be supplied or administered to a named patient after the prescriber has assessed the patient on an individual basis
In emergency situations, a prescriber may issue a PSD
which then may be documented retrospectively on the drug chart
Seen on inpatient hospital drug charts as directions to
medicate a named patient
PSDs are exemptions to the restrictions on drugs
outlines in the HMR 2012
Local organisation
medicines policies
Guidance and procedures in different situations at local level
Set out standards for authorised medicine use (reflect HMR)
Staff roles, responsibilities and limitations for medicine use
Audit trail
Risk management
NHS hospitals
Inpatient prescribing and administration chart
Is a PSD, i.e. an order for admin of drugs to a patient and not supply (not subject to same restrictions as normal prescription)
Prescribing standards in the Trust medicine policy
Paper or electronic
Discharge summary
TTOs/TTAs
Prescribed medication for patients on discharge
Prescribe sufficient to cover them until the discharge letter gets to their GP for continuation of the meds
Duration varies by Trust, usually min 14d
Hospital outpatient prescription
Hospital approved outpatient prescription
Use in-hospital pharmacy
FP10NHC outpatient prescription
Some Trusts allow prescription from these if to collect from
community pharmacy
FY1 not permitted to prescribe on these
(supply of meds not
in hospital itself, so not counted as 'supervised')
Legal aspects
Prescriber identifier
GP surgery address or GMC #,
or prescriber status
Not needed on hospital prescriptions
as it will already have these details on it
Indelible ink
All prescriptions (written or printed)
Signature of prescriber
Identifies prescriber
Should be handwritten (unless electronic
prescription sent direct to the pharmacy)
Date
Always date the prescription
Patient details
All prescriptions to have full name and address
(plus hospital number if inpatient)
Age/DOB if <12y
Legal requirement for age/DOB to be present
Controlled drugs
Classification
Misuse of Drugd Regulations (2001)
Defines individuals authorised to supply/possess CDs
Classified into Schedules for use in medicine
Most are Schedule 2/3, rarely 1
Misuse of Drugs Act (1971)
Classes A,B,C depending on level of harm
Higher class = higher penalty
Prescription
Pharamacist and nurse and supplementary prescribers
can if trained on CD prescription
BNF 'CD2' or 'CD3' symbols identify CDs
Fully registered doctors can prescribe Schedules 2/3
(FY1 can with supervisionary conditions)
Requirements
Basic
Age/DOB (if <12y)
Signed by prescriber
Name and address
Dated (CDs 2-4 only valid 28d)
Indeliable ink
Prescriber identifier
Specific
Total quantity
Quantity and number of dose units
should be stated in words and figures
e.g. for tablets, twenty (20) capsules
e.g. for oral solution, 30 (thirty) mls
Formulation
Must include (tablet, oral solution, IM, etc.)
Unused space
Block out to prevent additional
medicines being added fraudulently
Dose
As directed not acceptable
(but 1 as directed is)
Strength
But only if >1 strength is available
NICE standards
Prescribing
Separate prescriptions
for different routes with cross-ref
Communicate to patients GP
Indication, dose/regimen in medical notes
Current clinical need
Considerations
Patients full MH
Opioid naive or not
Benefit/risk
Evidence base
Licencing
Classification of
medicinal products
MHRA provides marketing
authorisation for UK medicines
Classes
Pharmacy medications
restricted to sale in pharmacies
Prescription only medications
Only accessed with a prescription
General sales list medicines
Sold to public in pharmacies, supermarket etc
Unlicenced drugs do not have a UK
marketing authorisation
(senior clinicians only)
Off label drugs have a marketing authorisation but for a different indication/dose/patient group
(check off label use is approved e.g. BNF)
Criteria for use of
unlicenced/off label meds
Sufficient evidence base
Prepared to take responsibility for the decision
No suitable licenced alternative
for the patients needs
Fully documented prescription and rationaile
Inform patient and gain consent
Good prescribing practice
7 Deadly Sins
of prescribing
Inappropriate abbreviations,
decimals and leading zeros
Fail to calculate and check doses
Illegible prescription
Fail to take an accurate DH
Not knowing the drug
Not knowing the patient
Fail to give clear instructions
Decimals and zeros
Avoid trailing zeros e.g. 5.0mg or 0.5g
Don't use decimal points where possible
Decimal points ok if range e.g. 0.5-1g
Abbreviations
Drug names in full
Dose units in full
Avoid where possible
For strength, g and mg OK,
everything else in full
e.g. micrograms, units
Inpatient prescribing
standards
Generics and brands
Good practice to prescribe generically
(flexible supply and costs)
Exception when drugs have different preparations/release/bioavailability,
also good for initiating therapy
Allergy status
Agent and type of reaction on drug chart;
if none, then state NKDA
PRN meds
Indicate a max daily dose
Provide the indication
Route and site
State on drug chart, single route if possible
Multiple routes should be documented separately
and cross referenced to prevent dosing errors/OD
Check if route change changes the dose
Variable regimens
e.g. warfarin based on INR
Additional info should be documented in patients notes
Reviewing and cancelling
Cancelling
Cross through whole entry
Sign and date the cancellation
Document changes and rationaile in notes
Amending
Re write prescription in full
Document in notes
Reviewing
Regularly review
Stop unnecessary meds
Document and date reviews
Formularly and
prescribing guidelines
Formularies
Non-forulary drugs can be requested
Most trusts have own formulary of what
drugs are available at the trust
Policy, protocol
and guidelines
Within limits and expertise
Restrictions on certain meds
e.g. cytotoxic chemotherapy
Local and national policy
Principles of
good prescribing
National and local guidance
Unambiguous, legal prescriptions
Effective, safe and cost-effective choices
Monitor effect and SEs
Patient ideas, concerns, expectations
Communicate prescribing decisions
Consider other factors affecting tx
Prescribe within limits of knowledge and experience
Consider patients PMH/DH first
Be clear about reason