2: Charting and Prescription Writing - Mahoney Flashcards
where do lab tests and radiologic evalations go in the SOAP note?
objective or plan
8 major parts of prescription
date name superscription inscription subscription signa renewal signature
SISSY
superscription inscription subscription signa your signature
which drugs can never be renewed without a new written prescription
oxycodone
hydrocodone
the Rx
superscription
name and strength of drug
inscription
directions to the pharmacist
subscription
includes dosage form and is usally preced by disp
directions to patient
signa
instructions as to the route of administration, the amount of drug to be taken, and the time and frequency of the dose
a.c.
ante cibos
before meals
b.i.d.
bis in die
twice a day
caps.
capsula
capsules
c
cum
with
gtt.
gutta
drops
H.S.
hora somni
at bedtime
p.o.
per os
by mouth
p.c.
post cibos
after meals
p.r.n.
pro re nata
when necessary (as needed)
q.
quaque
each, every
q.i.d.
quarter in die
four times daily
stat.
statim
immediately
tab
tabella
tablet
t.i.d.
ter in die
three times daily
I.V.
intravenous
subQ
subcutaneous
I.M.
intramuscular
h.
hora
hour
teaspoon =
5 cc or 5 ml
tablespoon =
15 cc or 15 m;
1 oz = _____ ml
30
1 pint = _______ ml
473
renewal requirements for sched. III or IV drugs
no more than 5 times w/i 6 mo of date of issue and can be prescribed over the phone or via fax
can sched.II drugs be renewed?
may not be renewed adn cannot be phoned or faxed to pharmacy
however, 3 separate 30 day supply prescriptions for schedule II drugs and submit to pharmacy with same date on each prescription
“take as directed”
NEVER write this
when do you use a zero
before a decimal point but never as a trailing zero
what law do you follow?
the strictest law regardless of governmental level, always takes precedence unless federal law is preemptive
heroin
marijuana
LSD
mescaline
schedule I
high abuse no med use
no prescription
opioid
amphetamines
sedatives
schedule II
high abuse potential with severe psychological or physical dependence liability
must be WRITTEN prescription
codeine sulfate codeine phosphate oxycodone Hcl hydrocodone ritalin
schedule II
codeine phosphate + acetaminophen (tylenol w/ codeine)
anabolic steroids
schedule III
phenobarbital chloral hydrate lirium valium serax klonopin ativan
schedule IV
potential for limited physical or psychological dependence
codeine containing cough mixtures
schedule V
may be dispensed w/o prescription in certain states
DEA number?
federal registration number
must be written on each prescription for schedule II-IV drugs
in some states also V
morphine
sched. II
5 most common drugs implicated in adverse events
vicodin ibuprofen acetaminophen cephalexin penicillin
4 most commonly mishandled drugs leading to errors by physicians
vancomycin
morphine
cefazolin
acetaminophen
factors that led to adverse event
- failure to detect a disease state contraindication to the drug therapy
- failure to detect a significant drug interaction
- failure to detect a significant drug allergy
- failure to prescribe the correct dose
- failure to monitor drugs with narrow therapeutic indices
- patient knowledge deficits
