When a patient comes to a doctor, an encounter happens, this encounter would lead to certain stages. -> would eventually end up in a prescription of medication or intervention that is meant to alleviate the patient’s condition.

Hallmark of the profession -> writing a prescription.

Prescription – comes from the word ‘prescribe’ (you are given something)

a written order or instruction of a validly registered prescriber to a dispenser for the use of a specific drug product for a specific patient

o usually written but now can be given verbally or it can be electronically generated.

a legal documento therefore all the requirements for a

legal document should be there can be computer generated specially in the

US

When a patient comes to a physician,

A patient – physician encounter usually results in a prescription

o If there is no prescription,

patients feel that their visit to the physician is not completed or fulfilled

physicians feel that they have not fulfilled their role if the patient is not issued a prescription

The RIGHTS of a prescription:

The right patient The right drug The right dosage – amt to be administered The right dose The right route of administration – the best

route that is most suitable for the condition

The right date, number of refills – because not all prescriptions need to do a refill

The correct duration of treatment The right to informed consent- inform the

patients on the medication/drugs you intend to prescribe the patient

o You have to spend some time with your patient.

The right to refuse treatment- the patient can refuse treatment after you have explained what is necessary

o Has the option to accept or refuse the treatment

o Patient has also the right to seek another opinion, so do not be hurt or insulted when a patient seeks a 2nd

opinion because it’s a right.

As doctors, it is a responsibility to prescribe the most appropriate, best recommended, most suitable drug for the patient.

Important to know what you are prescribing.

PRESCRIPTION WRITING OBJECTIVES

*Correctness of Form

1.) Simplea. There should only be one drug per

prescriptioni. First mentioned in Generic Act of

1988 but is amended such that it now allows more drugs in a prescription but for SIMPLICITY just one drug per prescription.

2.) Neata. No erasures, no unnecessary marks, the

paper you’re going to use should be cleanb. Neatness also speaks of your personality

3.) Legiblea. If you’re a doctor, it doesn’t give you a

right for an illegible handwriting.b. a legible handwriting speaks of the

writer’s willingness to communicate”

Subject: PharmacologyTopic: Intro to Prescription WritingLecturer: Dr. Dela CruzDate of Lecture: Transcriptionist: Pages:

SY 2

011

-20

12

i. if it can’t be understood, how can you communicate?

ii. Writing is a form of communication

c. to avoid medication errorsd. It is the legal duty of a Physician to write

legiblyi. Some deaths have already

resulted because of wrong interpretation of an illegibly written prescription

Sample Handwriting of a Physician

Prescribed: Avandia: an anti-diabetes drugInterpreted: Coumadin: an anticoagulant.

Results

failure to take the drugs for diabetes (blood sugar increased tremendously)

since Coumadin: anticoagulant – can cause bleeding – effect can be fatal

4.) Written in inka. The ink has to be blue or blackb. It’s a medico-legal document

i. Contract between a patient and a doctor

c. Erasures on a prescription can easily lead to dispensing errors or abuse of controlled substances

i. Will not be accepted by the drugstore because it is suspicious of tampering especially for controlled substances

5.) Provide precise, clear and specific directionsa. Clear to the patient

i. To avoid medication errorii. Most important should be given

first6.) Use of Generic Name

a. Mandated by law (Generics Act of 1988)

Three Names by which a Drug is Known

Chemical Nameo Exact chemical derivation/

composition of drugo Not suitable for prescriptiono Ex. N-acetyl-p-aminophenol

(Paracetamol) Generic Name

o Also called as official or non-proprietary name

nobody owns the generic name

o given by an official agency e.g. World Health

Organizationo based on the chemical name

commonly, sounds like the chemical name but is shortened

o scientifically and internationally recognized active ingredient of the product

o names are decided by the World Health Organization (WHO)

o Ex. Paracetamol (U.S.P.) or Acetaminophen (B.P.)

Brand name/Trade name/ Trademarko commercial property of a

pharmaceutical company that manufactures the product

(same chemical, same drug) Name given to a drug to

distinguish it as being a manufacturer’s product

o also called as Proprietary name

Registered trademark - ®o Company spends enormous amount

of money in its promotion Claims it as their own so they

promote it as their product Manufacturer assumes

quality and consistency of the product

Drugs with brand names are more expensive than drugs with generic name

o Ex. Biogesic, Tempra, Calpol, Tylenol

Advantages of Using the Generic Name1. Universality

o proprietary names differ from country to country

o a drug would only have one Generic name (even if you go to different countries)

o avoids duplication2. Clarity

o gives information to which class the drug belongs

nomenclatureo group similarities are immediately

apparento e.g.

Beta blockers (– olol)

Propranolol, Metoprolol, Acebutolol

Penicillin (-cillin) Amoxicillin,

Ampicillin3. Economy

o Cheaper, less expensiveo usually but not always

4. Convenienceo allows substitution

allows the pharmacist to supply whatever version of the drug is in stock

allows cheaper drug to be chosen

Disadvantages of Using the Generic Name1. Difficult to spell or recall

e.g. Carboxymethylcysteine/Carbocysteine (Solmux, Loviscol)

o Too long2. Questioned Therapeutic equivalence/

Therapeutic inequivalenceo quality of generic drugs

o perception that generic drugs are less effective than branded ones.

o task of duly constituted authorities to assure that generic and branded medicines are pharmaceutically and biologically equivalent

all drugs passes through BFAD, therefore all quality control has been done to assure that the products are of good quality.

Correctness of Form (cont.)

7.) Written in English or the language best understood by the patient

a. It should be understood by the patient8.) Capitalization of appropriate letters

a. First letter of the name of drugs and dosage form

b. T in Tablet, S in Syrup should be capitalized, no need to capitalize all letters

9.) Correct spelling and grammar10.)No abbreviations

a. source of miscommunicationb. errors in interpretation (subject to

different interpretations)c. substitution of drug with converging

names but with divergent effects (errant substitutions)e.g.

i. Isordil for anginaii. Iselpin for peptic ulcer

d. Dose distortions e.g.

i. cc could be misinterpreted as c.c. (cum cibum - with meals)

ii. gr. for grain can be confused with gram large dose difference

iii. Use of the degree symbol (º) for hours (every 4º) or for primary (1º)

iv. o.d. for once a day, may be interpreted as “for the right eye”

*Precision in Dosage

Use of Metric System of weights and measureso weights: grams, mg, microgramso volume: ml (not cc), litero if it’s more than 1 gram = write gramo if it’s less than 1 gram = write mgo if it’s less than 1 mg = write mcg

mcg not μ g should be used for microgram

Units of the metric system is preferred instead of household measures (e.g. dropperful, teaspoonful, etc)

o If you use them be sure that the teaspoon is equivalent to 5ml because usual teaspoons are only 4ml.

o Tablespoon should be 15ml to ensure precision because usual tablespoon is only 10ml.

Use of calibrated droppers provided by the manufacturer or use standard dropper issued by pharmacist.

o For every ml, 20 grams. Use Arabic rather than Roman numerals

o Since the prescription is in English, use Arabic numerals.

If there is a decimal point,o which preceeds the number, you put a 0

before the decimal point - (leading Zero)

to emphasize the position of the decimal point

e.g. 0.2o Never use trailing zero’s

e.g. 2.0 You do not need to put a

decimal point. Variation in dosage is allowed for as long as you

don’t exceed 10% (exemption in variation : very potent drug –comes in mcg)

o 513 mg ® 500 The number of prescribed drug should match the

number expected based on the duration of treatment

Dispense in specific quantitieso Do not prescribe 10.5 tablets; if you

need an added 0.5, then you use 11 instead of 10.5.

o When they come in liquids, utilize the volume of the bottle that is closest to the

total required volume. *Should be more rather than less. – so that it is enough for the duration of treatment

Prescribe only the specific no. of doses until follow-up

o So that the patient will comply with follow-up appointments, to check if he/she is responding to the treatment

Requirements for Precision in Dosage: Usual dose Size of the available preparation or strength

of the preparation Frequency of administration

o based on 16 waking hours – if it is not noted to be taken round the clock.

if the instruction is to take the table every 4 hours, it is based on 16 waking hours (4 times a day)

o round the clock (24 hours)- if the instruction is to take

the table every 4 hours round the clock, then you have to have 6 doses.

Duration of treatmento So you’d know the total number to

be dispensed.

PARTS OF THE PRESCRIPTION

1. SuperscriptionName of patient & Address for identification and record keeping

purposes to insure or assure that the correct

medication goes to the correct patient

AN IMPORTANT CAVEAT® Do not write a prescription for someone you

have not seen.® Remember that no clinician-patient

relationship is established when the patient is not seen.

Age a requirement in pediatric and elderly

patients to insure the appropriate use of drug and

dose avoid age-inappropriate prescriptions

® For medications whose dosage involves calculations, the patient’s weight or body surface area should also be listed

Date a medico legal document establishes the temporal relationship

between patient-physician encounter and the time the prescription is filled

monitor compliance behaviors

recognizing potential problems

Symbol symbol for medical prescription without Rx, it is not a medical prescription

**not exactly Rx but an R with a tail and a bar crossing it

has three possible derivations: Eye of Horus Sign of the planet Jupiter abbreviation for the Latin word

“recipere” The symbol Rx is derived from the major lines in the symbol of the Eye of Horus. The Egyptians considered it a symbol of good and restored health.

The sign of the planet Jupiter; as such it was placed upon horoscopes and upon formula containing drugs made for administration to the body, so that the harmful properties of these drugs might be removed under the influence of the lucky planet.

Rx is an abbreviation for the Latin word recipere, which means “to take” or “take thus.”

2. Inscription – body Generic name of the drug Clearly indicated dosage form

e.g. Tablet, Capsule, Syrup, Solution for Injection

Size of the available preparation (tablet) or strength/concentration of the preparation (liquid)

e.g. 500mg tablet, 250 mg/5 ml., 2%

3. Subscription direction to the dispenser –> Pharmacist contains the total quantity to be dispensed

based on the frequency of administration and the duration of treatment

written as Dispense no. – total amount to be dispensed

Do not substitute # for no. should be the appropriate quantity for the

full course of treatment

4. Signatura / Label direction to the patient patient and drug specific preceded by the word Label or Sig.

Starts with the manner or route of administration:

Take (oral)

Give (pediatric/if person cannot take the drug by himself)Instill or place (drops) Apply (topical)Insert (suppositories)For injection (parenteral)

simple directions must be clear and concise in language that is best understood

by the patient, should be brief but precise

instruction on when and how to take medications

Do not use the phrase “Take as directed” or A.D. because it often leads to:

Non-compliance Patient confusion Medication error

® Dose – how much of the drug is to be taken e.g. 1 tablet

® Frequency of administration – how often e.g. every four hours

® Duration of treatment – to be able to compute for total amount to be dispensed

e.g. for 5 days, for 7 days® Specify the indication - encouraged

reminds the patient of the drug’s purpose confirm to the pharmacist the

appropriate medication® Special instructions or Warnings

Non- refillable or for refill Take with food Shake well before using

5. Prescriber’s Data Name and Signature Initials M.D. after the prescriber’s name License no. / PRC no. PTR no. – Professional Tax Receipt No. S2 or Opium license no. (if you’re prescribing

controlled substances)

® Use your own name + MD in writing Rx otherwise you prescription will be entirely wrong (for exam purposes also )

® Your signature signifies your full liability of the prescription

“At this point in your life, you will now practice to write or attach the initials MD after your name. You have to get used to the fact that eventually you’re going to be doctors and you will have that MD sign after your names.” – Dr. Delacruz

SCHEDULE OF CONTROLLED SUBSTANCES

Schedule I high potential for abuse NO accepted medical use or lacks accepted

safety profile if used for treatment

may be used for research purposes by properly registered individuals

® ILLEGAL drugs: Heroin, Methylene dioxymethamphetamine (MDMA) or Ecstasy, Lysergic acid diethylamide (LSD), Mescaline

Schedule II high potential for abuse some has a currently accepted medical use abuse of substance may lead to severe

psychological and physical dependence prescription of these drugs are limited,

CANNOT be refilled

® morphine, codeine, and opium® hydromorphone, methadone, meperidine

(pethidine), oxycodone, and fentanyl ® amphetamine, methamphetamine,

dextroamphetamine, methylphenidate, cocaine, amobarbital, glutethimide, and pentobarbital

Schedule III abuse potential less than Schedule I and II

substances has a currently accepted medical use abuse may also produce dependence refills are allowed if authorized in the

prescription may be refilled up to 5 times within 6 months

after the date when the prescription was issued

® Anabolic steroids (used by athletes to enhance their performance)

® Vicodin ni Dr. House

Schedule IV abuse potential less has currently accepted medical use abuse of substance may lead to limited

dependence relative to substances in schedule III

® IV narcotics i.e. propoxyphene ® Alprazolam, clonazepam, clorazepate,

diazepam, lorazepam, midazolam ® Zolpidem

Schedule V Buprenorphine ® products containing a low

dose of an opioid plus a non-narcotic ingredient, e.g.:

® Codeine (low dose opoid) + Guaifenesin (non-narcotic ingredient) as cough syrup

• cough preparation contains not more than 200 milligrams of codeine per 100 milliliters

or per 100 grams (Robitussin AC®)

® Diphenoxylate (present in small amount in Lomotil) plus atropine for diarrhea

lower potential for abuse relative to substances listed in Schedule IV

consist primarily of preparations containing limited quantities of certain narcotic and stimulant drugs

generally used as antitussive, antidiarrheal and analgesic

Prescription for a controlled substance must include the following information:

Date of issue Patient's name and address Practitioner's name, address, and S2 number Drug name, strength and dosage form Quantity prescribed Directions for use Number of refills (if any) authorized Manual signature of prescriber

Types of Defective Prescriptions:1. Violative Prescriptions

♦ Generic name is not written♦ Generic name is not legible , brand

name is legibly written♦ Brand name is indicated and an

instruction such as “no substitution” is added

2. Erroneous Prescriptions♦ Brand name precedes the generic

name♦ Generic name is the one in

parenthesis♦ Brand name is not in parenthesis

3. Impossible Prescriptions♦ Only the generic name is written but

not legible ♦ Generic name does not correspond

to the brand name ♦ Both the Brand name and Generic

name is not legible♦ Drug product is not registered with

BFA

Parenteral Drugs & Skin Test

Use parenteral for emergency situations. Not all parenteral drugs use skin test, there

are “inject only after negative skin test”.o Exemption (does not need skin test):

drugs that are used for life threatening conditions.

If the preparation is likely to cause an allergic reaction, like an antibiotic, you need to do a skin test.

Legal implications, if the skin test is negative, then you give the drug and it gives an allergic reaction, you will not be legally liable because you did the skin test.

How to do a skin test:

You have to reconstitute the preparation.

Get the vial, add 1.5ml (so it’s liquid already). Then get 0.1ml of that, then add 0.9 ml

distilled water. Use a tuberculin syringe, then inject at the

forearm intradermally (just beneath the dermis), 10-25 degrees angle of the needle.

o Amount to be injected: just enough to do a 1cm wheal.

Mark the borders of the wheal with a ball pen then observe for 30 minutes.

o It is positive if there is redness, swelling, itchiness beyond the marked borders of the wheal

When the result is equivocal (you cannot say it’s positive or negative, there is swelling but did not go out of the borders), in the other arm, make another wheal from the same solution then 2 inches away from the site, you do a negative control, use a distilled water and make another wheal then observe for 30 minutes.

Legal implication – if the skin test is negative and after administering the drug the patient developed an allergic reaction, the physician is not liable because the skin test is not 100% reliable.

Sample Prescription: Solid, oral

Nikky Javier SuperscriptionSilang, Cavite Aug. 7, 2009

Paracetamol Tablet 500 mg Inscription Dispense no. 12 Subscription

Sig: Take one tablet every 4 hours, as necessary Signatura for 3 days.

Ma. Luisa D. Delacruz, M.D. Prescriber’s dataPRC Lic. No. 49339PTR no. 2345680

“…as necessary”® Include in prescribing drugs for symptomatic relief only® Do not include in prescribing for definitive treatment

Sample Prescription: Liquid, oral

Nikky Javier, 8 yrs old SuperscriptionSilang, Cavite Aug. 7, 2009

Paracetamol Syrup 250mg/5ml Inscription Dispense no. 1 bottle (60 ml) Subscription

Sig: Take one teaspoonful every 4 hours, Signatura as necessary for 3 days.

Ma. Luisa D. Delacruz, M.D. Prescriber’s dataPRC Lic. No. 49339PTR no. 2345680

*1tsp (5ml) x 4hrs = 20 x 3days = 60ml

Sample Prescription: Liquid, parenteral

Nikky Javier, 8 yrs old Superscription Silang, Cavite July 27, 2011

Paracetamol Solution for Injection 150mg/ml Inscription Dispense no. 12 ampules Subscription

Sig: For Injection. Inject 1 ml intramuscularly Signatura every 4 hours, as necessary for 3 days.

Ma. Luisa D. Delacruz, M.D. Prescriber’s data PRC Lic. No. 49339

PTR no. 2345680

Nikky Javier, 8 yrs old Superscription Silang, Cavite July 27, 2011

Amoxicillin for Injection 500 mg Inscription Dispense no. 20 vials Subscription

Sig: For Injection. Dissolve the contents of 1 vial in 1.5 ml distilled water and inject intravenously Signatura every 6 hours round the clock. Inject only after a negative skin test.

Ma. Luisa D. Delacruz, M.D. Prescriber’s data

PRC Lic. No. 49339PTR no. 2345680

Remember: dissolve the contents of the vial, not the vial!

“INJECT ONLY AFTER A NEGATIVE SKIN TEST” – indicated in the prescription if the preparation can induce an allergic reaction. (see part on HOW TO DO A SKIN TEST)

END TRANSCRIPTION