7. Composing Prescription&Referral

8/19/2019 7. Composing Prescription&Referral

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Prescription & ReferralPrescription & Referral

• “Letters” only legal physicians haethe rights to !rite" Physicians # doctors, dentists, ets

" Legal # certi$ed, registered, licensed• %ritten instr&ctions to o&r colleag&es

" O&r colleag&es # pharmacists, doctors ' dentistsspeciali(ing in other disciplines, la) technicians

" *e polite, do not appear a&thoritarian" *e caref&l !ith !hat yo& !rite do!n

" May )e &sed for medico+legal iss&es• o& can )e serio&sly s&ed !hen ma-ing

mista-es 2


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What must be mentioned ?What must be mentioned ?

/./. o&r identity ' !here yo& !or- o&r identity ' !here yo& !or-

" Physician0s name ' license n&m)er

" 1nstit&tion or Clinic0s name, address,

phone ' o2ce ho&rs" 1nforming the recipients of ho! to

contact yo& again, 3&st in case theyneed to.

• o&r hand!riting is &nreada)le• o& order some )i(arre dr&g name or dose

• o&r instr&ction is &nspeci$c, ..etc..

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4. Date4. Date

" Stating the e5act date the instr&ction is

gien

" 1nforming the recipient of the e5act date

yo& instr&ct the patient to see him

• Patient feels )etter decides not to )&y the

prescri)ed dr&gs one day, the symptoms

rec&r the old prescription # 1678L1D

prescription same symptoms 9 samedisease

• 8 patient s&:ering of an ac&te in;ammatory

disease prescri)ed !ith a high+dose S81D

goes to the pharmacy < days later1678L1D rescri tion the in;ammation

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=. o&r Signat&re=. o&r Signat&re

" Sign yo&r instr&ction )rie;y

" P&t yo&r name ' degree &nderneathyo&r signat&re

" 7alidating yo&r instr&ction

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PrescriptionPrescription• %ritten instr&ction from a physician to a

pharmacist concerning the name, formand dosage of a dr&g to )e iss&ed to acertain patient

• 8 comm&nication medi&m " )et!een physicians and pharmacists

• >ransparent, )&t concealed

" >ransparent not to )e p&t inside a sealedenelope

" Concealed !ritten in Latin codes ' Romann&merals

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How to make aHow to make aPrescription ?Prescription ?

/. Choose the right dr&g

" >he right diagnosis of the disease

" >he right dr&g gro&p ? regarding thedisease

" >he right form 'dose ? regarding thepatient• 8llergic to certain s&)stance @

• Patented or generic @

4. Start Composing the Prescription

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Composing a PrescriptionComposing a Prescription• yo&r 1D ' !here yo& !or- top of the paper

• Date• Dr&gs

" 8l!ays )egin !ith RA

" /st line• 6ame 8mo5ycillin Poidon 1odine oral gargle

• B&antity


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Prescri)

ed dr&gs

Deisy Radithia, drg., SpPM.S1P 6o. /4=IAPDJ1A71A4K

“Oral Perfection Clinics” " Dr. Soetomo = S&ra)aya


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R e f e r r a lR e f e r r a l• 8 recommendation to cons&lt other

professionals, from other disciplines

• 8 comm&nication medi&m

" )et!een physician and other physician

• CO6E1D6>18L sealed enelope

" 1t contains yo&r patient0s condition in details

!hich m&st )e respected and protected

• S&spicion of diagnosis

• nderlying systemic disease infection,

degeneratie, neoplasm

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2 types of Referral2 types of Referral

/. See-ing diagnosis

4. See-ing treatment

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See-ing diagnosisSee-ing diagnosis

• Clinical diagnosis is )ased onanamnesis ' clinical e5aminationneeds con$rmation, )y !hat0s so+called “S&pporting 5amination”

" Radiography• 1maging techniT&e

" Cytology• 8ll a)o&t cell shape, co&nt, U

" Vistology• 8ll a)o&t tiss&e tiss&e str&ct&re, U

" Molec&lar 8nalysis• Jenomics ' proteomics D68, R68, proteins,

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NoteNote

• S&pporting e5amination is meantto con$rm a s&spicion

• Only refer !hen yo& hae already

)&ilt &p a clinical diagnosis• Refer to the right recipient

• Vae an e5pectation of seeral

conditions !hich might appear inthe res&lt and )e prepared !ithseeral treatment plans

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Refer to theRefer to the rightright recipientrecipient

• RadiographyRadiography" Radiology or RWntgen

• CytologyCytology

" Micology ' *acteriology Micro)iology" *lood, &rine ' stool Clinical Pathology

• VistologyVistology" >iss&e *iopsy Pathology 8natomy,

S&rgery

• Molec&lar 8nalysisMolec&lar 8nalysis" 5pert in Molec&lar *iology

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How to compose?How to compose?

• *e polite

• *rie;y e5plain the patient0s

complaints ' condition• Clearly state the intended

e5amination

• %rite do!n yo&r s&spicion orclinical diagnosis

• *e co&rteo&s “>han- o&”

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Referring the patient or theReferring the patient or thespecimen @@specimen @@

• Referring the patient" Clearly state the location of the intended

e5amination and type of lesion

• Referring the specimen

" passed a training or !or-shop in ario&s)iopsy techniT&e@ perform it yo&rself,then simply send the specimen

" Clearly state

• >he original location of the specimen and type ofthe lesion

• *iopsy ' $5ation techniT&e

• transport media

• Patient0s 1D if yo&r specimen is inalid, thepatient can )e contacted to )e re+)iopsied

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See-ing treatmentSee-ing treatment

• %hen the disease needs to )e treated)y other disciplines, )eca&se

" >otally irreleant

" Releant, )&t the treatment )elongs toother disciplines

" Releant, )&t !e do not possess thenecessary facilities

• 8fter )eing referred, the patient might)e

" totally dismissed from o&r care and receief&ll treatment from other physicians

" Receiing parallel treatment the diseaseneeds integrated therapy

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keywordkeyword

!ohon perawatan lebih lan"ut dibidang #e"awat$

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>reating the patient in parallel>reating the patient in parallel

• 1f the disease manifests in the oral caity" Dia)etes, Vypertension, Syphilis, V17+81DS,

8llergy, M&co+c&taneo&s diseases, Cancer, U

• Refer to physicians in releant e5pertise !hile giing

treatment for the oral lesions

• 1f treatment in o&r discipline is complicated

)y other conditions

" lcer located near a sharp+edged tooth caity

• refer to Operatie Dentistry or Oral 'Ma5illofacial

S&rgery

" Patient !ith Dia)etes needs tooth e5traction

• refer to 1nternist to reg&late )lood s&gar leel )efore

proced&re

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keywordkeywordPenderita masih dalam perawatan kami$

%r

#imply mention the treatment plan of your

discipline

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• Composing prescription ' referral is

technically easy

• Qeep practicingU practice ma-es

perfect

• [&st remem)er to )e polite, )rief ')e polite, )rief '

speci$cspeci$c

• Do not gie an impression of )einga&thoritarian

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B&estiB&esti

ons @@@ons @@@

Deisy adithia! drg"! #$%&081931542642deisy'radithia(yah))"c)*

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7. Composing Prescription&Referral