Transcript How to Write a Prescription -Dr. Marco

Catherine A. Marco, MD, FACEP
Goals & Objectives
 Describe the proper physician-patient relationship
 Describe clinical decision making regarding
medication prescriptions
 Delineate the basic components of a written
prescription
The Physician-Patient
Relationship
 Patient identification
 Establish diagnosis
 Treatment plan, options, counseling
 Follow-up care
 Online or telephone evaluations are not adequate
 A pharmacy may not fill a controlled substance
prescription in the absence of a proper physician-patient
relationship
Prescription
 A prescription order is written for diagnosis,
prevention or treatment of a specific patient's disease
 Is written by a licensed practitioner
 Is written as part of a proper physician-patient
relationship
 Is a legal document, "prima facie" evidence in a court
of law.
Over-The-Counter -OTC
 Patient can use drug safely by reading the labeling
instructions.
 Examples
 analgesics like aspirin and ibuprofen
 topical antibiotics
 Cough and cold remedies
 Some vitamins
Rx Only Drugs
 Can only be dispensed on a prescription order
 Synonyms: Legend (or dangerous)
 Physician training required to use safely
 Examples
 Most systemic antibiotics
 Cardiovascular drugs
 Most drugs that have dependence liability
Controlled Substances
 Drugs with abuse potential
 Classification CI, CII, CIII, CIV, CV
 Schedule III,IV, V are obtained on a regular prescription
 Must include date
 Must include prescriber DEA#
 Schedule II drugs require an “official” Rx form
 (formerly used a “triplicate Rx”)
 Schedule I, some drugs (chemicals) may not be available
by any legal means
 Heroin
 LSD
Schedule I
 The drug or other substance has a high potential for
abuse.
 The drug or other substance has no currently accepted
medical use in treatment in the United States.
 There is a lack of accepted safety for use of the drug or
other substance under medical supervision.
 Some Schedule I substances are heroin, LSD,
marijuana, and methaqualone.
Schedule II
 The drug or other substance has a high potential for
abuse.
 The drug or other substance has a currently accepted
medical use in treatment in the United States or a
currently accepted medical use with severe restrictions.
 Abuse of the drug or other substance may lead to
severe psychological or physical dependence.
 Schedule II substances include morphine, PCP,
cocaine, methadone, and methamphetamine.
Schedule III
 The drug or other substance has a potential for abuse
less than the drugs or other substances in Schedules I
and II.
 The drug or other substance has a currently accepted
medical use in treatment in the United States.
 Abuse of the drug or other substance may lead to
moderate or low physical dependence or high
psychological dependence.
 Anabolic steroids, codeine and hydrocodone with
aspirin or Tylenol, and some barbiturates are Schedule
III substances.
Schedule IV
 The drug or other substance has a low potential for abuse
relative to the drugs or other substances in Schedule III.
 The drug or other substance has a currently accepted
medical use in treatment in the United States.
 Abuse of the drug or other substance may lead to limited
physical dependence or psychological dependence relative
to the drugs or other substances in Schedule III.
 Included in Schedule IV are Darvon, Talwin, Equanil,
Valium and Xanax.
Schedule V
 The drug or other substance has a low potential for abuse
relative to the drugs or other substances in Schedule IV.
 The drug or other substance has a currently accepted
medical use in treatment in the United States.
 Abuse of the drug or other substance may lead to limited
physical dependence or psychological dependence relative
to the drugs or other substances in Schedule IV.
 Over-the-counter cough medicines with codeine are
classified in Schedule V.
Parts of the Prescription
 Rx (an abbreviation for "recipe," the Latin for "take thou.“)
 Superscription (Patient Information)
 Inscription
 Subscription
 Signa
 Date
 Signature lines, signature, degree, brand name indication
 Prescriber information
 DEA# if required
 Refills
 Warnings
Patient Information
 Name
 Address
 Age (Required on triplicate or “official”)
 (30y/o)
 Weight (optional, but useful)
 Time-(inpatient medication orders)
Inscription
 What is the pharmacist to take off the shelf?
 Drug Name
 Dose = Quantity of drug per dose form
 Dose Form = The physical entity needed, i.e.
 tablet, suspension, capsule
 Simple vs Compound Prescriptions
 Manufactured vs compounded prescriptions
 Clarity of number forms 0.2, 20| not 2.0
 (Zeros lead but do not follow!)
Subscription
 What is the pharmacist to do with the
 ingredients?
 Quantity to be dispensed (determines amount in
 bottle) Dispense # 24
 For controlled substances write in numbers and
 letters (like a bank check)
 #24(twenty four)
 Any special compounding instructions
Signa, Signatura or Transcription
 Instructions for the patient
 Route of administration: Oral, nasally, rectally, etc
 Take by mouth.., Give, Chew, Swallow whole, etc.
 Number of dosage units per dose
 (Take one tablet, Give two teaspoonfuls, etc).
 Frequency of dosing (every six hours, once a day, etc.)
 Patient lifestyle, inpatient schedules (compliance)
 Duration of dosing (...for seven days,... until gone, ...if needed for




pain).
Purpose of medication for pain, for asthma, for headache, etc.
Avoid “As directed”
Special instructions (shake well, refrigerate etc.)
Warnings
Refills and Date Prescribed
 Indicate either no refills or the number of refills you
 want (don’t leave it blank)
 Date the prescription
 All prescriptions expire after one year
 Schedule II drugs can only be dispensed within 6
months of date on RX
Signature of the Prescriber
 This makes the prescription a legal document
 Include your degree
 One signature line
 You must write “brand necessary” or “brand medically
necessary” to get non-generic agent.
 Electronic Rx’s coming!
D.E.A. Registration Number
 Drug Enforcement Agency (DEA)-US Government
 Also enforced by Texas Dept. Public Safety (DPS)
 DEA# is needed on any controlled substance (CII-CV)
Communicate Before You
Medicate!






Tell patient the name of the drug and what it is for.
Tell your patient exactly how to use the medication
Warn them of possible problems
What to do if dose is missed
Cost (source?) and storage
Review Rx for possible for errors
Common Abbreviations
 qd or od = every day
 po = by mouth (orally)
 qod = every other day
 IV = intravenous
 bid = twice daily
 IV push or bolus = at one time
 tid = thrice daily
 IV infusion = infuse over time
 qid = four times/day
 IM = intramuscular
 ac = before meals
 stat = immediately
 pc = after meals
 sq or sc = subcutaneous
 hs or qhs = at bedtime
 sig = signa or signetur =
 disp = dispense
 prn = as needed
directions for use
 Qod and qid can get mixed up; qod and qd can get
mixed up.
 One solution is to write out “once a day” or “once every
other day” or “four times daily.”
 This brings up the confusion between q6h and qid.
 Does this medication require a strict 6-hour dosing
interval?
 Or, can it be given four times daily, for example, in a
6:30 AM to 11:00 PM day?
Telephone Orders
 Telephone orders may be placed for drugs in Schedules III, IV, and V.
 A written prescription is required for ordering drugs in Schedule II.
 In an emergency, a prescription for Schedule II drugs may be telephoned to
a pharmacy. If the pharmacy is willing to accept the telephone order, only
enough drug to cover the emergency may be prescribed. The physician is
then required to supply a written prescription to the pharmacy within 72
hours. The pharmacist is required to call the "Feds" if he doesn't receive the
prescription within 72 hours.
 "Emergency" means that the immediate administration of the drug is
necessary to proper treatment, that no alternative treatment is available,
and that it is not possible for the physician to provide a written prescription
order for the drug at that time.
Risk Management Strategies for Prescribers
 BE PROFESSIONAL AND COURTEOUS
 KEEP GOOD RECORDS
 PROVIDE ADEQUATE AND INFORMED CONSENT
 TELL AND ALLOW PATIENTS TO CALL WHEN NECESSARY
 PROVIDE THE PATIENT WITH A REALISTIC ASSESSMENT OF
OUTCOME, BENEFIT, AND ADVERSE REACTIONS
 DO NOT SUPPORT FALSE EXPECTATIONS
Let’s Write the Prescription!
John Smith
4/12/10
25
Ankle sprain
NKDA
Motrin 600 mg tablet
50 tabs
one
po Three times daily
1
Catherine Marco, MD
Catherine Marco, MD
PRN Pain
Questions?