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Year 3 - Script > Prescription Documentation > Flashcards

Prescription Documentation Flashcards

1
Q

how should the dosage of drug be written

A

only Grams (g) and milligrams (mg) may be abbreviated - all other dose units should be written in full

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2
Q

Is it a legal requirement for the form (e.g. tablets) to be stated on a prescirption for a controlled drug

A
  • Yes

- it is a legal requirement for the form to be state on a prescirption for a controlled drug

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3
Q

How much quantitiy of medicines should be supplied when a patient leaves hospital

A
  • The quantitiy of medicines supplied on discharge can vary between hospital trusts
  • discharge teams should ensure patients have sufficient supply to meet their requirements up until they can arrange for a new prescription from the gP
  • decision is made with the patient
  • hospitals will often state a maximum lenght of time for the supply of controlled drugs (e.g. 7 or 14 days)
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4
Q

What does the human medicines regulations 2012 do

A
  • Sets out the legislation surrounding the authorisation of medicines for human use in the UK
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5
Q

What does the human medicines regulations 2012 act include

A
  • manufacture
  • import
  • distribution
  • sale
  • supply
  • labelling and advertising
  • monitoring (pharmacovigilance)
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6
Q

who can prescribe

A
  • docotors

- dentists

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7
Q

What are the types of non medical prescribers

A
  • Supplementary prescribers

- independent prescribers

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8
Q

Name some professions that can be Supplementary prescribers

and independent prescribers

A
  • Dietitians (SP)
  • Nurses and midwives (IP/SP)
  • optometrists (IP/SP)
  • Pharmacists (IP/SP)
  • physiotherapists (IP/SP)
  • podiatrist (IP/SP)
  • radiographers SP
  • Advanced paramedics (IP/SP)
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9
Q

Who can issue a FP10NC, FP10HNC or FP10SS and what colour is it

A
  • Green

- issued by GPs, Hospital, independent, and supplmentary prescribers

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10
Q

who can issue an FP10PN or FP10SP

and what colour is it

A
  • Lilac

- nurse independent and supplementary prescribers

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11
Q

Who can issue an FP10D and what colour is it

A
  • yellow

- Dentists

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12
Q

Who can issue an FP10MDA adn what colour is it

A
  • Blue

- it is used to prescribe drugs of misuse and to manage opioid dependence (e.g. methadone or buprenorphine)

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13
Q

who can issue an FP10PCDNC/SS and what colour is it

A
  • Pink

- used in the private (non-NHS) sector to prescribe shedule 2 and 3 controlled drugs

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14
Q

What are patient specific directions (PSDs)

A
  • range of expemtions (listed by the human medicines regulations 2012) to the restrictions on the sale, supply and administration of medicines
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15
Q

Give some examples of PSDs

A
  • PSDs are what we see in the hospital setting on inpatient drug charts as directions to administer a medicine to a named patient
  • in an emergency situations an independent prescirber may verbally issue a PSD to administer a medicine these can then be retrospectively applied on the drug chart
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16
Q

How do you define a PSD

A
  • written instructions form a doctor dentist or other independent prescriber for a medicine to be supplied or administered to a named patient after a prescriber has assessed the patient on an individual basis
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17
Q

what do medicine policies set out

A
  • set out local standards and requirements for the management of medicines
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18
Q

what is the aim of the medicines policies

A
  • set out the principles by whcih medicines are to be prescribed stored, transported, supplied and administered within a clinical setting and therefore usually closely reflect the requirements of the human medicines regulations 2012
  • ensure that all members of staff working within the hospital are aware of their roles responsibilities and limitations with respect to medication
  • provide an auditable trail for the handling of medicines including the use of controlled drugs
  • help manage the risks that medicines can pose to patients, service users, residents and staff to ensure that service users receive appropriately prescribed medication safely and effectively
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19
Q

List what prescirptions would be used in a hospital

A
  • Inpatient prescribing and administration chart
  • discharge summary
  • hospital outpatient prescription
  • FP10HNC outpatient prescription
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20
Q

Describe how Inpatient prescribing and administration chart are used

A
  • Inpatient drug chart is a PSD
  • these document the drug treatment to be given to a patient during their inpatient stay
  • subject to prescribing standards outlined within the trust medicines policy or code
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21
Q

Describe what discharge summaries are used for

A
  • TTOs (to take out) or TTAs( to take away) these are used to prescribe medication to be given to inpatients upon discharge
  • you would prescribe sufficient medication to allow time for the discharge summary to reach the patients GP for medication to be continue
  • minimum of 14 days is usually recommended
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22
Q

What is a hospital outpatient prescription

A
  • Prescribe for an outpatient using a hospital approved outpatient prescritpion
  • dispensed at the hospital pharmacy department
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23
Q

Who can not prescribe on an FP10HNC

A
  • foundation year 1 doctors are not permitted to prescribe on these as the supply of the medicine can be made outside of the hospital premises and the prescribing is not considered supervised
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24
Q

in an FP10 prescription how does a singature need to be written

A
  • signature must be handwritten
25
Q

When can an prescirption be electronic

A
  • a prescription can be electronic on an FP10 prescription only on prescirptions that are transferred to a community pharmacy electronically
26
Q

what does an advanced electornic signature mean

A
  • uniquely linked to the prescriber giving the prescirption
  • capable of identifying the prescriber
  • created using a method that can be maintained and soley controlled by the prescriber - e.g. smart card
  • linked to the data to which it relates (e.g. any subsequent changes to the data are detectable)
27
Q

for patients under 12 years old what it is a legal requirement to state

A
  • it is a legal requirement that the prescription states the patients age or date of birth for patients under 12 years
28
Q

is it a legal requirement for the date of birth to be stated on an inpatient drug chart

A
  • not a legal requirement
  • but date of birth along with hopsital number to vertify patient details is used to identify the patient at the point of administration
29
Q

What are the basic legal requirements of a prescritpion

A
  • patient detials
  • signature of prescriber
  • prescriber identifier
  • date
  • indelible ink
  • age/date of birth if you are under 12
30
Q

What patient details should be on a prescription

A
  • full name
  • address of the patient
  • (in hospital you put the patients hospital number)
  • NHS number should be included
31
Q

What should patient prescriber information include

A
  • address of the prescriber - must be within the UK

- professional number or prescribing status

32
Q

What are the classes of drugs according to the misuse of drugs act 1971

A
  • Class A
  • Class B
  • Class C
  • the classes reflect the level of harm the drug may cause to an individual
33
Q

What does the miuse of drug regulations 2001 do

A
  • defines the groups of individuals who are authroised to supply and possess CDs and lays down the conditions under which this may be carried out
34
Q

What does CD stand for

A
  • controlled drugs
35
Q

Who has a licence to prescribe CDs

A
  • doctors, dentists and vet surgeons hold a licence to prescribe CDs(except schedule 1)
  • F1 doctors are not permitted to prescribe CDs within the supervisory conditions of their employment
36
Q

How do you know if a drug is controlled

A
  • schedule 2 and 3 preparations are identified by the symbols CD2 and CD3
37
Q

what are the requirements on a prescription of controlled drugs

A

Basic requirements

  • name and address of patient
  • age or date of birth if under 12
  • signed by the prescriber (not electronically)
  • dated (prescriptions for schedule 2,3 and 4 CDs are only valid for 28 days)
  • be written so as to be indelible
  • contain a prescriber identifier

additional requirements

  • dose
  • form of the preparation, even if only one form is available
  • strength
  • total quantitiy of the preparation or the number of dosage units in both words and figures
38
Q

What should you take into account when prescribing CDs

A
  • the benefits and risks
  • patients full medication history
  • whether the patient is opioid naive
  • evidence based resources
39
Q

what should you do if you prescribe a CD

A
  • document the indication and dosing regimen in the patients medical notes
  • assess the patients current clinical need and adjust the prescription as appropriate
  • discuss with the patient how their treatment will be reviewed and monitored
  • be able to discuss prescribing decisions with other healthcare professionals
40
Q

what should you do when prescribing a “when required” CDs

A
  • document clear instructions for when and how to take or use the CD in the patients medical notes
  • annotate the dosae instructions on the prescription (e.g. maximum dose and frequency)
  • consider any pre-existing supplies of the CD the patient may have at home prior to supplying on discharge
41
Q

How do you prescribe a CD that has mutiple routes

A
  • you should clearly document on the prescription when each route can be used and clearly cross-reference to prevent any accidental overdose by dual administration via both routes
42
Q

what is the classification of licensed drugs

A
  • General sales list medicines - available for general sale
  • Pharmacy medicines - those medicines restricted to sale through pharmacies
  • Prescription only medicines -to be prescribed by registered practitioners only
  • Controlled drugs - all of which are POM status to be prescribed y registered practitioners only
43
Q

What is meant by an unlicensed drug

A
  • Unlicensed products do not have a UK marketing authorisation
44
Q

What is meant by off label prescribing

A
  • Off label prescribing refers to the use of a drug that does have a marketing authorisation but where its use is outside the terms of its licence
  • may be at a different dose indication or patient group outlined in the summary of product characterstics
45
Q

How do you know if a medication is off label approved

A
  • indciated in the BNF
46
Q

To prescribe off label what must you be satisfied with

A
  • there is no suitable licensed alternatives that would meet the patients needs
  • there is sufficient evidence base and/or experience for its use
  • you must be prepared to take responsibility for prescribing the unlicensed medicine and for overseeing the patients care
  • your decision has been documented in the medical notes including the rationale for the prescription
47
Q

what abbreviations are approved

A
  • QDS - 4 times a day
  • SC - subcutaneous
  • mg - milligrams
48
Q

where should the allergy status of a patient be documented

A
  • in both the medical notes and on the inpatient chart

- absence of information should not be taken as an indication that the patient has no known allergies

49
Q

What are exceptions to the rule of using generic names for prescribing

A
  • different preparations of the same drugs have different release mechanisms or bioavailability profiles = in this case brand name should be used
50
Q

give some examples of brand prescribing

A
  • immunosuppresants
  • antiepileptics
  • some modified released preparations
51
Q

What does PRN mean

A

as required

52
Q

what should you indicate on an “as required” prescription

A

Maximum dose

  • maximum dose and frequency at which the as required medication should be administered
  • this avoids excessive dosing

Minimum dose interval
- the length of time between doses should be stated to avoid doses being given in quick succession

Indication
- annotae the prescription with the reason for prescribing or indication

53
Q

What should you do when reviewing prescriptions

A
  • review all medication regularly
  • stop any unnecessary medication
  • consider documenting review dats, both within the patients nodes and on the inpatient chart
54
Q

What should you do when cancelling a prescription on an inpatient drug chart

A
  • Cross through the entire entry
  • annotate the entry with your signature and date
  • do no obliterate the entry in its entirety - remember that hte originally prescribed and administered items are still part of your patients medical history
  • document any changes to your patient’s prescribed therapy in the medical notes including the rationale for change
55
Q

What should you do when amending a dose or frequency

A
  • re-write the prescription in full

- make an entry in the medical notes

56
Q

what does a trust formulary do

A
  • a trust formulary limits the number of drugs within the hospital which helps manage the risks of prescribing and healthcare costs
57
Q

what should you do if you want to prescribe a drug that is not included within the formulary

A
  • the pharmacotherapy committe or drugs and therapeutics committee consider requests on a case by case basis
  • this should be documented in the medical notes
58
Q

What are the 10 principles of good prescribing

A
  1. be clear about the reasons for prescribing
  2. take into account the patients medication history before prescribing
  3. take into account other factors that might alter the benefits and risks of treatment
  4. take into account the patient’s ideas, concerns and expectations
  5. select effective, safe and cost-effective medicines individualised for the patient
  6. adhere to national guidelines and local formularies where appropriate
  7. write unambiguous, legal prescriptions using the corret documentation
  8. monitor the beneficial and adverse effects of medicines
  9. communicate and document prescirbing decisions and the reason for them
  10. presribin within the limitations of your knowledge, skills and experience

Year 3 - Script (11 decks)

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