Transcript Prescribing in Practice Part 1 (c)

Prescribing in Practice
Part 1 (f)
Responsibility and Record Writing
Responsibility
• The practitioner can only prescribe for a patient who
they have assessed.
• Community practitioners may only prescribe on her
own personal prescription pad.
• In the absence of the patient’s original assessor who
has initiated the first prescription the community
nurse may write a repeat prescription or order
repeat doses in order to preserve continuity of care.
• All prescribers have a responsibility to report suspected
adverse drug reactions
ADRs
• Only prescribe when there is a need to prescribe
• If patient is pregnant or breast feeding only prescribe if
absolutely necessary
• Always establish if the patient has allergies or previous
reactions to medications
• Establish if the patient is taking any other medications
• Consider age, renal and hepatic function
• Prescribe as few drugs as possible and start low and go
slow if appropriate
• Only prescribe drugs you are familiar with
• Inform the patient of potential reactions
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Record Keeping (e.g. NMC,
2010)
Accurate
Legible (handwriting)
Unambiguous
Contemporaneous
Relevant
Sufficient
Dated, timed and signed
Signature printed alongside signature
Date prescription written
Name & profession of prescriber & if IP/SP
Name of drug, dose, route, formulation, duration
(See Principle 7
NMC 2010)
Record Keeping
• The record of the prescription should be entered into
the nursing notes and medical records at the time of
writing the script or as soon as practically possible
thereafter at the very latest within 48 hours or by
local arrangement.
(Standards as in NMC (2010) Record Keeping
Guidelines apply)
• Sometimes it might be necessary to inform another
member of the team that a prescription has been
issued. In this case that action should be recorded
in the nursing notes.
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