Transcript Practice Basics

Chapter 13: Processing
Medication Orders
and Prescriptions
Inpatient Pharmacies
 Receiving Medication Orders
 hand-delivered
 mechanical method
 fax transmission or pneumatic tube
 Computer physician order entry, or CPOE
 orders verified by pharmacisst
 Telephone orders
 by prescriber or an intermediary
 legal restrictions
Upon Receipt
 2 steps
 review order for clarity & completeness
 prioritize the order
Ideal Medication Order
 Patient name
 Rate & time
 Hospital identification #
 Indication
 Room/bed location
 Other instructions
 Generic drug name
 Prescriber’s signature
 Brand drug name*
 Printed name if needed
 Route of administration
 Credentials
 Dosage form
 Pager number
 Dose/strength
 Date & time of order
 Frequency & duration
Prioritization
 PATIENT DISCOMFORT
 initial treatment of pain, fever, or nausea & vomiting are
generally high priority
 Urgent orders are filled first
 Evaluate by analyzing:
 route
 time of administration
 type of drug
 intended use of drug
 patient-specific circumstances
Order Start Times
 STAT – immediately- an urgent need
 “Now” or “ASAP”
 “start today” or “start this morning”
 Has 1st dose of medication been given? (ER)
 Standard amount of time to process & deliver order
 typical turnaround times in hospital


15 minutes for STAT order
1 hour for a routine order
 Technicians use critical thinking skills to prioritize
orders
Processing Medication Orders
 Identify patient
 Compare order with patient’s existing medication
 Order entry steps
 choose correct medication from database
 identifying administration schedule
 enter any special instructions
 Medication must be selected, prepared or
compounded, checked, dispensed for use
Patient Profile
 Patient name
 Names of admitting &
 Identification numbers
consulting physicians
 Allergies
 Medication history
 Special considerations
 Clinical commentstherapeutic monitoring,
counseling notes
 Date of birth/age
 Sex
 Height and weight
 Lab values
 Admitting/2nd diagnoses
 Room & bed number
Selecting Drug Product
 Drug may be ordered by generic or brand name
 Abbreviations often used
 Lists of abbreviations that cannot be used
 Look-alike & sound-alike drug strategies
 store in separate locations
 additional labeling
 tall man letters (example: buPROPion – busPIRone)
Drug Selection
 Mnemonic is code, associated with medication
 Ampicillin 250 mg
 mnemonic, or drug code, “amp250,”
 choices:



amp250c ampicillin 250 mg capsule
amp250s ampicillin 250 mg/5 mL oral suspension
amp250i ampicillin 250 mg injection
Order Processing
 Labels generated upon order entry
 IV label format different from unit dose tablet
 Form of medication
 pediatric
 meds through tubes (nasogastric tubes or gastric tubes)
 Formulary considerations
Order Processing
 Pharmacist input
 consult pharmacist if any warnings appear
 Computer warnings:
 interactions
 duplications
 allergies
 dosage range
 diluent choices

may be standardized as defaults in computer system
 Final step-pharmacist verification of all orders
Medication Administration Times
 Administration time impacts:
 drug efficacy
 diagnostic laboratory testing
 Pharmacokinetic studies using administration time in
relation to lab test time to determine drug dose
recommendation
 Full stomach or empty stomach
 Standard medication administration times
Standard Administration Times
 daily = 0900 (9 a.m.),
 bid = 0900 and 1700 (5 p.m.)
 q8h=every 8 hours = 0600 (6 a.m.), 1400 (2 p.m.), and
2200 (10 p.m.)
 Warfarin – 1700 to allow time to review lab results
 Standardized schedules of drug administration
 based on therapeutic issues, nursing, pharmacy
MAR
 Medication administration record
 Part of patient’s medical record
 Nurse documents when medication administered
 Standardized times appear as default entries on MAR
 Default times may differ on some specialized units
 “daily” may default to 0900
 physical rehabilitation unit

might require daily administration to occur at 0800
Scheduling Considerations
 Must be aware of exceptions
 Pharmacists must consider other medications
 ciprofloxacin & calcium carbonate must be spaced
 day or days of the week
 important to coordinate with patient’s home schedule
 every-other-day orders

avoid advising caregiver to give medication on odd days or
even days, because depending on number of days in month,
“every other day” will change with respect to odd/even
Information System
 Physicians’ orders are input into patient profile in
pharmacy information system
 Information used to generate:
 MARs
 medication profiles
 fill lists (for pharmacy use)
 labels for medications to be issued to patient care areas
 MARs may be either paper or electronic (eMAR)
Special Instructions
 Pharmacy instructions
 notes between pharmacist/technician
 clinical notes
 Nursing instructions
 storage information
 administration instructions
 physician-specified parameters
 displayed on MAR & medication label
Sample Inpatient Order Entry
 Enter patient’s name/account number-verify pt
 Compare order to patient profile in detail
 Enter drug
 Verify dose
 Enter administration schedule
 Enter any comments in clinical comments field
 Verify prescriber name
 Fill & label medication
Filling, Labeling, Checking
 Send enough doses to last to next scheduled delivery
 24-hour cart fill system common
 Review label carefully
 against order
 against product
 Medication order is filled
 Pharmacist checks-legally required in most cases
 Technology-order images archived
Special Considerations
 “Charge-Only” & “No-Charge” Entries
 Pharmacist protocols
 Diagnostic preparation orders
 Computer physician order entry
 Automated dispensing technology
 Centralized dispensing automation
 Decentralized automation
Outpatient Pharmacies
 Receiving Prescriptions
 presented in person
 telephoned in from prescriber’s office
 facsimile
 electronic transmission
 Refill requests
 internet
 phone


manual-uses person
automated system
Payer Information
 Establish:
 primary payer for prescription
 patient’s portion of reimbursement (copayment)
 drug formulary
 Electronic claims adjudication
 Prescription may be held until information gathered
Clarity & Completeness
 Patient name
 Quantity to be dispensed
 Patient home address
 Number of refills
 Date written
 Substitution (DAW)
 Drug info
 name
 strength
 dose
 Directions
 route
 Frequency & duration
 Signature/credentials
 DEA # if required
 Prescriber’s info
 name, address, phone
 indication (not
required, but
recommended)
Dispense as Written (DAW)
 DAW= brand name drug written must be dispensed
 Some states require phrase “Do Not Substitute” (DNS)
 Must consider state law & pharmacy policy
 Preprinted areas-prescriber signs to designate “DAW” or
“generic substitution acceptable” ok in some states
DAW codes
0 = No product selection indicated
1 = Substitution not allowed by provider
2 = Substitution allowed- patient requested product
3 = Substitution allowed- pharmacist selected product
4 = Substitution allowed- generic drug not in stock
5 = Substitution allowed- brand drug dispensed as generic
6 = Override
7 = Substitution not allowed- brand drug mandated by law
8 = Substitution allowed- generic drug not available in
marketplace
9 = Other
Forgeries
 Screen prescriptions for controlled substances
 May be fairly easy to identify
 erasure or overwriting of strength or dispensing quantity
of drug (changing 3 to 8)
 More subtle
 theft of preprinted prescription pads
 legitimate-looking prescriptions
 telephoned in to pharmacy
Other Considerations
 Legibility problems & interpreting abbreviations
 Patient notification if
 contacting prescriber
 medication is not in stock
 Prioritization
 order in which presented to pharmacy
 common-sense judgment
Patient Profile
 Patient’s name/identification number
 Date of birth/age
 Home address/telephone numbers
 Allergies
 Principal diagnoses
 Primary healthcare providers
 Third-party payer(s)/other billing information
 Over-the-counter medication/herbal supplements
 Prescription & refill history
 Patient preferences
Prescription Entry
 Appropriate drug product selection
 mnemonic
 alphabetical listing
 National Drug Code (NDC) number
 Directions for use
 Fill quantity
 Initials of pharmacist checking prescription
 Number of refills authorized
Primary Prescription Label
(information may vary by state)
 Patient’s name
 Date the prescription is being filled (or refilled)
 Prescriber’s name
 Sequential prescription number
 Name/strength/manufacture
 Quantity dispensed
 Directions for use
 Number of refills remaining/associated refill period
 Expiration date
 Physical description of med if required by state law
Instructions for Use
 Administration directions (“Take,” “Insert,” “Apply”)
 Number of units constituting one dose/dosage form
 Route of administration
 Frequency
 Duration if applicable (“for 10 days,” “until finished”)
 Indication if applicable (ex: “for pain” or “for blood
pressure”)
Outpatient Prescription Process
 Enter patient’s medical record number or name
 Enter or verify existing third-party billing information.
 Compare order to patient profile in detail
 Enter drug
 Enter label direction mnemonic
 Enter comments
 Enter prescriber’s name
 Enter amount to dispense/refill information
 Fill & label the prescription