Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Clinical Pod Med Exam 1 > 2 - Writing Progress Notes and Prescriptions > Flashcards

2 - Writing Progress Notes and Prescriptions Flashcards

1
Q

NOTE

A

There will be no questions on writing progress notes, just use those slides for SPAL prep

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the purpose of a prescription?

A
  • A prescription is an order for a specific medication for a specified patient at a particular time
  • It is the way a health professional communicates a patient’s selected drug therapy to the pharmacist and instructs the patient on how to use the prescribed medication
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How can you write or give a prescription?

A

The order may be written and signed or it may be given orally directly to a pharmacist

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How common is it for patients to misuse a prescription?

A

25% to 50% of patients do not use the prescription as intended, with most errors attributable to the prescription order itself

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How are most prescriptions submitted today?

A

Electronically

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the EIGHT parts of a prescription order?

A

KNOW THIS (“SISSY”)

  • date prescribed
  • name (address, and age) of patient
  • superscription (S)
  • inscription (I)
  • subscription (S)
  • signa (S)
  • renewal information
  • signature of prescriber (your signature) (Y)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Why is the date prescribed important?

A

Under the Controlled Substances Act, certain drugs can’t be dispensed or renewed more than 6 months from the date prescribed.

Some can never be renewed without a new written prescription (oxycodone and hydrocodone)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Why is the name, address and age important?

A

Identifies the person for whom the drug is intended.

Name is all that is generally needed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is a superscription?

A

The Rx, a contraction of the Latin verb “recipe”, meaning “take thou”.

Serves to introduce the drug prescribed and the directions for use.

Not commonly found on the prescription, but will be on the medication container.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is inscription?

A

Name (trade name, generic, or chemical), and strength of drug (use metric terms)

When the trade name is written, the prescription must be filled with the product of the specified manufacturer, unless the prescriber and the patient approved a substitution with another brand

Can indicate this at the end of the prescription by selecting DAW (dispense as written) or generic - most pharmacists will substitute a generic to save the patient money, so indicate if you do not want this.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Describe writing for a mixed drug

A

If two or more drugs are to be mixed together by the pharmacist, list each separately directly below the preceding one

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is a subscription?

A

Directions to the pharmacist

  • State the specific dosage form [number and form of medication (tablets, capsules, ounces, mls)] to be dispensed or the desired method of preparation
  • Usually preceded by “Disp” (Dispense)
  • WRITE OUT BOTH WAYS: Disp: Twenty-eight (28) capsules
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is signa?

A

Directions to the PATIENT

  • Preceded by Sig. (Signa, meaning “mark thou”)
  • Instructions as to the route of administration, the amount of drug to be taken , and the time and frequency of the dose
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What should you avoid saying to patient?

A

Avoid phrases such as “take as directed” or “use as needed”

Although used extensively, avoid Latin abbreviations, and write in long hand to avoid mistakes on the part of the pharmacist or the patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What should you use for numbers and units?

A

Write out numbers- do not use i, ii, iii to represent 1, 2, 3

For liquids, use teaspoon (5 cc or 5 ml), tablespoon (15 cc or 15 ml), or drops when appropriate

1 oz = 30 ml and 1 pint = 473 ml

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Give an example of how you should write a prescription

A

Sig.: One (1) capsule four (4) times a day one (1) hour before meals

“¡ cap q.i.d. ¡ h. a.c.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Describe renewal information

A
  • Number of refills of the prescription that are authorized by the prescriber
  • Drugs that bear the legend “Caution: federal law prohibits dispensing without prescription” may not be renewed without the expressed consent of the prescriber.
18
Q

Describe renewal of scheduled drugs

A
  • Schedule III or IV drugs may be renewed no more than 5 times within six months of date of issue and can be prescribed over the phone or via fax
  • Schedule II drugs may not be renewed and cannot be phoned or faxed to pharmacy
19
Q

What does DEA allow?

A

However, DEA will allow prescriber to write up to three separate consecutive prescriptions (each for a 30 day supply) for 90 day supply for schedule II drugs and submit to the pharmacy with the same date on each prescription.

20
Q

What are some tips to prevent misuse of drugs

A
  • Use legible writing
  • Do not use abbreviations
  • Include indications for use
  • Use a zero before a decimal point (0.5 rather than .5 mgs)
  • Never use a trailing zero (5 rather than 5.0)
  • Include age and weight when appropriate
  • Prohibit “take as directed” instructions
21
Q

Question: The part of the prescription that conveys instructions to the pharmacist is called the

A

Subscription

22
Q

Describe the controlled substances act

A

CSA

  • Legal aspects of prescription writing and dispensing are incorporated in various federal, state, and local laws
  • The strictest law regardless of governmental level, always takes precedence unless Federal Law is preemptive
  • CSA imposes even more stringent controls on the distribution of all stimulant and depressant drugs and substances with the potential for abuse as designated by the Drug Enforcement Agency (DEA)
  • Divides drugs with abuse potential into 5 categories or schedules
23
Q

Describe schedule I drugs

A
  • High potential for abuse with no currently accepted medical use in the US
  • Heroin, marijuana, LSD, mescaline, etc.
  • Not available with a prescription, other than for medical marijuana
  • May be obtained for research
24
Q

Describe medical marijuana

A
  • As of May 2014, 22 states and Washington D.C. have legalized the use of medical marijuana
  • CO and WA voted to legalize recreational use of marijuana for citizens over 21
  • April, 2015: CA federal judge refused to remove it from list as Schedule 1 drug
25
Q

What is the ‘Respect States and Citizens Rights Act’?

A

Aims to amend the Controlled Substances act to exclude any state that has legalized marijuana (for medical OR recreational use) from marijuana provisions of the CSA, effectively giving state law precedence over federal law

26
Q

Describe schedule II drugs

A
  • High abuse potential with severe psychological or physical dependence liability
  • Certain opioid drugs, preparations containing amphetamines or methamphetamines as the single active ingredient or in combination with each other, and certain sedatives
27
Q

Describe schedule III drugs

A
  • Less potential for abuse than schedule I or II

- Use may lead to low or moderate physical dependence or high psychological dependence

28
Q

Describe Tylenol #3

A
  • Codeine phosphate + acetaminophen [Tylenol w/codeine (Tylenol #3®)] is a schedule III drug
  • This is strange because codeine alone is a schedule II drug
29
Q

What is another example of a schedule III drug?

A

Anabolic steroids (nandrolone, oxandrolone)

30
Q

Describe schedule IV drugs

A
  • Potential for limited physical or psychological dependence

- Examples: Phenobarbitol, chloral hydrate, Librium®, Valium®, Serax®, Klonopin®, Ativan (don’t need to know drugs)

31
Q

Describe schedule V drugs

A
  • Potential for less abuse than those listed in schedule IV.
  • Buprenex®, Lomotil®, codeine-containing cough mixtures
  • Some of these may be dispensed without a prescription in certain states
32
Q

Describe registering with the DEA

A

You must register each year with the DEA to obtain your federal registration number, called your DEA number which must be written on each prescription for Schedule II through IV drugs (in some states, also V)

33
Q

Morphine is a schedule ___ drug

A

II

34
Q

Describe the name of the prescriber

A
  • Signature of prescriber at bottom of prescription (name and address of office or prescriber usually printed at top of prescription) to validate prescription
  • On oral prescriptions, the pharmacist adds the prescriber’s name to the prescription
35
Q

What is NEEDED for a schedule II drug?

A

However, for schedule II drugs, the prescriber must provide a written prescription to the pharmacist

36
Q

Describe medication adverse effects

A

In 2008, “1.9-million people became ill or injured from medication side effects or because they took or were given the wrong type or dose of medication, compared with 1.2 million injured in 2004,” according to a statistical brief from the Agency for Healthcare Research and Quality

37
Q

What are the 10 most common drugs implicated in adverse events

A
  • Insulin
  • Anticoagulants
  • Amoxicillin
  • Aspirin
  • Bactrim/Septra
  • Vicodin/Norco *
  • Ibuprofen *
  • Acetaminophen *
  • Cephalexin *
  • Penicillin *
38
Q

What are the 10 most commonly MISHANDLED drugs leading to errors by physicians

A
  • Insulin
  • Morphine *
  • Potassium
  • Albuterol
  • Heparin
  • Vancomycin *
  • Cefazolin *
  • Acetominophen *
  • Warfarin
  • Furosemide
39
Q

What factors lead to adverse medication events?

A
  • 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 (always ask before applying topical antibiotic)
  • Failure to prescribe the correct dose
  • Failure to monitor drugs with narrow therapeutic indices
  • Patient knowledge deficits
40
Q

Select the TRUE statement
a - Hydrocodone can be prescribed over the phone
b - Oxycodone can be given refills on one prescription
c - You can refill a schedule III drug no more than 5 times in a 6 month period
d - Codeine phosphate with acetaminophen is a schedule II drug

A

c - You can refill a schedule III drug no more than 5 times in a 6 month period

Clinical Pod Med Exam 1 (17 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions