Types of prescribers and prescriptions

Question 1

What are the types of prescribers (7)

Answer 1

1. dentists
2. nurses
3. pharmacists
4. radiographers
5. physiotherapists
6. chiropodists
7. podiatrists

Question 2

What must prescribers do to become prescribers (2)

Answer 2

1. undergo further specialist training.
2. Each prescriber type has different restrictions on what they can and can not prescribe.

Question 3

What are the different types of prescriptions (9)

Answer 3

1. Hospital - Green FP10NC
2. Nurse prescriber - FP10P/FP10SP
3. GP (England) - Green FP10SS
4. GP (Wales) - Green WP10
5. GP (Scotland) - Orage GP10
6. GP (Northern Ireland) - Green HS21
7. Pharmacist prescriber - Green FP10
8. Dentist - Yellow FP10D
9. Substance misuse clinic - Blue FP10MDA

Question 4

What are the NHS prescription legal requirements (6)

Answer 4

1. Age of patient if under 12 years
2. Patient name and address
3. Prescriber signature
4. Dated: Valid for six months from the date on the prescription. The exception is a repeatable prescription
5. Indication of the type of prescriber
6. Address of prescriber

Question 5

What is EPS/ETP (4)

Answer 5

1. Electronic prescription service (EPS) or the electronic transfer of prescriptions (ETP)
2. a way for prescribers to send NHS prescriptions via a secure NHS IT network to a pharmacy.
3. The way EPS prescriptions are handled is different and it is important that you know the processes involved if you have the service in your pharmacy.
4. The roll out of EPS has varied across the UK.

Question 6

What are Repeat Authorisation (RA), Repeat Dispensing (RD) scripts and electronic Repeat Dispensing (eRD) (9)

Answer 6

1. allow a patient to obtain repeat supplies of medication, via a batch of prescriptions, without needing to request them for a certain period of time, as indicated by the prescriber.
2. The prescriber issues a signed authorisation form (which is valid up to a year) known as a repeat authorisation (RA) script.
3. With the repeat authorisation forms, the prescriber issues repeat dispensing scripts (RDs or eRDs)
4. The repeat authorisation and repeat dispensing scripts are taken to the customers chosen pharmacy.
5. The pharmacist keeps the repeat authorisation script in the pharmacy.
6. The customer could either keep the repeat dispensing (RD) scripts, or ask the pharmacist to look after them.
7. With eRD, the prescriber authorises and issues the batch of repeat prescriptions electronically.
8. The next time the customer needs their medicine, the relevant repeat dispensing script is used.
9. It is good practice for the pharmacy to inform the customer when dispensing the last RD script so they can then see their GP for their next RA and RD script batch.

Question 7

How do serial prescriptions work in Scotland (3)

Answer 7

1. Serial Prescriptions (SRx) are written by prescribers for a period of up to 12 months with a specified dispensing interval (such as every 30 days).
2. The patient should be registered at the pharmacy for the medicine care review service (MCR).
3. They can be processed for payment each month electronically.

Question 8

What are private prescriptions (9)

Answer 8

1. Private prescriptions are not funded by the NHS and the patient must pay for the medicines prescribed.
2. They look different to NHS prescriptions and can be written on any piece of paper, except for controlled drugs, providing they contain all the required information to make them legally complete.
3. Each charge for a medication on a private prescription is different.
4. VAT is not charged on private prescriptions for human use, but it is charged on private prescriptions for veterinary use, written by vets.
5. Pharmacists in the UK can dispense prescriptions written by doctors and dentists registered in another European Economic Area (EEA) country or Switzerland as long as the pharmacist is able to understand it and all prescription requirements are met.
6. These prescriptions must be treated in the same way as private prescriptions.
7. There are exceptions, controlled drugs and ‘specials’.
8. Most prescriptions can only be dispensed once.
9. Some private prescriptions with repeat instructions can be dispensed more than once.

Question 9

What following checks must be made when taking in prescriptions (8)

Answer 9

1. The customer’s name and address are on the prescription and are accurate
2. The age is stated if the patient is under 12 years of age
3. Whether the patient is exempt from prescription charges (if applicable)
4. The back of the prescription has been filled in completely and correctly (if applicable)
5. The prescription is signed by the prescriber and is in date
6. Whether the customer is going to wait for the prescription or call back
7. Whether the items are in stock or need to be ordered
8. The address of the prescriber, an indication of the type of prescriber

Question 10

What must be done on the back of the prescription (7)

Answer 10

1. Before the patient or representative leaves the pharmacy, check whether they have filled in the back of the prescription correctly if required to
2. Inform the patient on how long or when their script will be dispensed
3. Check if they have signed and marked the correct boxes if they are exempt from prescription charges.
4. Remember to ask for evidence if patients are exempt and mark the ‘evidence seen’ box accordingly.
5. You should never tick and sign for an exemption yourself (England only).
6. Real-Time Exemption Checking (RTEC) is a technical solution that is being rolled out in England.
7. The PMR system can automatically check a patient’s exemption and automatically apply it to the EPS prescription, to help to reduce fraud by ensuring prescriptions are claimed correctly.

Question 11

What are the most likely drugs to appear of forged/fraudulent prescriptions (2)

Answer 11

1. CDs
2. It is important to note that prescriptions for other drugs can also be presented as fraudulent.

Question 12

What factors may raise suspicion of forged/fraudulent prescriptions (10)

Answer 12

1. Hand-written amendments e.g. increasing the quantity, dose or items added by hand (particularly if the other items are printed)
2. Photocopied private prescriptions
3. Signature or handwriting of a familiar prescriber being different from normal
4. Incorrect colour of an NHS prescription
5. Prescription serial number has been flagged by the local ICB or other NHS body as a possible forgery
6. Spelling errors
7. Inappropriate quantity, dose or directions
8. The person presenting the prescription not appearing to be related to the patient (the prescription may have been stolen)
9. A CD on a non-standardised controlled drugs private prescription form
10. If you come across any suspicious activity with regards to CD prescriptions, refer them to your pharmacist to investigate them further.

Question 13

How do prescription charges work (6)

Answer 13

1. In England customers may need to pay prescription charges if they are not exempt.
2. In Scotland, Wales and Northern Ireland, patients who live in and have their prescriptions dispensed in their country of residence do not need to pay any prescription charges.
3. Each country has its own agreements on what pharmacy contractors will charge if they receive an NHS prescription from one of the other three countries.
4. Therefore, ensure you check with your pharmacist before charging for the prescription.
5. For example, in Northern Ireland, they do not charge for any prescriptions, regardless of which UK country it originates from.
6. Whereas England, Wales and Scotland have different arrangements with each respective country.

Question 14

When might some items incur more than one prescription charge (5)

Answer 14

1. some hormone replacement therapy products incur two charges to the patient because they contain two different drugs.
2. Combination packs attract one charge for each item within the pack unless it is a combination of different strengths of the same drug.
3. Patients who pay for their prescriptions need to complete the back of the prescription form.
4. As well as NHS prescription charges, there are private prescription charges.
5. Private prescriptions charges apply to all non-NHS prescriptions dispensed in your pharmacy and this includes veterinary prescriptions.

Question 15

What patients are exempt from paying prescription charges in England (14)

Answer 15

1. Children under 16 years
2. Anyone over the age of 60 years
3. Individuals aged 16, 17 or 18 years and in full-time education
4. Patients receiving Income Support or Employment and Support Allowance (ESA)
5. Patients who have a valid Medical Exemption Certificate
6. People who have a valid Prescription Prepayment Certificate
7. Person is entitled to or named on a valid NHS tax credit exemption certificate
8. Patient has a continuing physical disability that prevents them going out without help from another person and has a valid medical exemption certificate (MedEx)
9. The patient or his/her partner is getting Pension Credit Guarantee Credit (PCGC)
10. Patient is receiving Income-based Jobseeker’s Allowance, or Universal Credit and meet the criteria
11. Anyone with a prescription for free of charge contraceptives or treatment for some sexually transmitted infections
12. People with a valid War Pension Exemption certificate; this only applies to medical items used to treat the specific illness(es) or disabilities detailed on the certificate
13. Patients who have a valid Maternity Exemption Certificate – pregnant women and those who have had a baby in the last 12 months with a valid certificate
14. The patient a valid NHS certificate for full help with health costs (HC2) or is named on an NHS certificate for partial help with health costs (HC3)

Question 16

What is the NHS Hormone Replacement Therapy Prescription Prepayment Certificate (HRT PPC) (4)

Answer 16

1. purchased with a one-off payment
2. covers an unlimited number of certain HRT medicines for 12 months, regardless of why they are prescribed.
3. It does not cover all HRT medicines
4. patients may benefit from a general Prepayment Certificate bought to cover 3 or 6 months to cover all NHS prescriptions.

Question 17

What is done if evidence of exemption is not seen (4)

Answer 17

1. mark on the back of the prescription as ‘evidence not seen’
2. The prescription can still be dispensed if the customer has not brought in any evidence of their exemption
3. you will just need to mark the back appropriately and remind them that routine NHS checks are made to verify exemption
4. For electronic prescriptions, your pharmacy may have Real Time Exemption Checking (RTEC), where the PMR system automatically finds out whether a customer has a known exemption

Question 18

What is the refund form FP57 (4)

Answer 18

1. Some people may have applied for an exemption certificate and are waiting for it to come through.
2. For these people you will need to complete a refund form
3. called FP57 in England
4. WP57 in Wales.

Question 19

What is the prepayment certificate (4)

Answer 19

1. If a patient in England has to pay for multiple prescriptions it may be worth them having a prepayment certificate.
2. This allows them to pay a collective sum for either 3 months or 12 months and then they do not pay for their prescriptions for this period of time.
3. If they sign the back of the prescription and tick this declaration they should have a card or digital certificate to show you.
4. Patients can also purchase the pre-payment certificate online and by phone.

Question 20

What happens when validating exemptions (2)

Answer 20

1. Once you have made sure the exemptions are valid and any charges have been paid, you need to ask the customer whether they wish to call back or wait.
2. If your pharmacy uses dockets, there may be a space to record this information on the docket itself.

Question 21

How are EPS dispensed (4)

Answer 21

1. Electronic prescriptions can be sent directly to the pharmacy and can be printed in the pharmacy for dispensing.
2. A patient may also be given an EPS token - this has a barcode which can be scanned to download the electronic prescription from the NHS Spine.
3. Note that this process may vary in each country.
4. In Scotland a paper form is required to ‘pull down’ the electronic message.

Question 22

How are paper prescriptions dispensed (6)

Answer 22

1. When you hand a paper prescription on to the dispensary staff, they will assemble the prescription.
2. They have strict SOPs for completing this process.
3. An important part of this is the labelling, which is done using the dispensary computer.
4. This computer keeps records for each patient (Patient Medication Records or PMRs).

Question 23

What do PMR help with (7)

Answer 23

1. keep details of all the medication that has been dispensed for that patient in your pharmacy
2. if there have been any changes to the medication
3. alerts them to any possible drug interactions
4. any allergies the patient has
5. any specific requirements they have
6. if they are exempt from charges (only NHS prescriptions in England have exemptions or charges)
7. and in some cases what OTC medicines they have purchased in the past.

Question 24

What must be done when issuing dispensed items (9)

Answer 24

1. Confirming an individual’s identity before issuing dispensed items
2. calling out the full name of the customer and then asking them for confirmation of their address or date of birth.
3. SOP will identify when you need to refer patients to the pharmacist and what information you should provide to the patient or their representative when handing out dispensed items.
4. Remember to take care to protect their confidentiality, for example, if they can be overheard, do not ask them for all of their details.
5. Check your pharmacy’s SOP on handing out Controlled Drugs (CDs) and check with your pharmacist before handing these medications out.
6. When you are handing out CDs, you may have to ask the person collecting the medicine for evidence of their identity such as a driving license. Your pharmacist will inform you when this is the case.
7. The customer or their representative will have to sign at the bottom of the back of the prescription (as well as signing the bottom of the prescription as usual) to say they are collecting the CD.
8. If they do not have ID or refuse to sign the back, you must refer them to the pharmacist.
9. Also, look at your pharmacy SOP for handing out items from the fridge, or any notes that indicate the pharmacist would like to speak with the patient, or any additional information.

Question 25

What advice might there be for storage and maintenance (4)

Answer 25

1. Some items may need to be stored in the fridge, for example insulin.
2. Some may need to be stored in a cool, dry place
3. do not store them in the bathroom cabinet as heat and moisture can degrade the medicine.
4. All medicines must be stored out of children’s reach and sight.

Question 26

What advice might there be for expiry dates (4)

Answer 26

1. Some items may have a limited shelf life (the time in which a pharmaceutical product is within an acceptable condition to be effective) after they have been dispensed.
2. liquid antibiotics
3. certain eye drops
4. some tablets in special containers

Question 27

What advice might there be for how to take the medicine (3)

Answer 27

1. Some items need to be taken before or after food
2. or placed under the gum/top lip
3. or chewed in a specific way.

Question 28

What advice might there be for what some of the side effects are (3)

Answer 28

1. Some medicines may make people drowsy
2. or keep people awake
3. or some may cause constipation.

Question 29

What advice might there be for returning unwanted medicines

Answer 29

Returning unwanted medicines to your pharmacy for safe disposal.

Question 30

What must be done with a completed prescription with a note (4)

Answer 30

1. you must not hand it out without speaking to the pharmacist first.
2. It could be that the pharmacist needs to check something with the patient or give some advice
3. for example make sure the patient understands a complicated dose
4. or that the medication can cause some side effects that they need to be made aware of.

Question 31

What do accurate records mean

Answer 31

Accurate records mean if there is any query with the prescription, you have the most current information to refer to on the computer records.

Question 32

What must be done with changes in patient details (4)

Answer 32

1. it is updated on their PMR.
2. If the information on the prescription does not correlate to the information the patient is telling you, you will again need to refer this to the pharmacist or another senior member of the pharmacy team to confirm whether this is correct and the discrepancy.
3. In some cases, the changes may need to be relayed to the patient’s GP
4. for example if they have changed their address and the GP still has them registered under an old address.

Question 33

What is the importance of containers (2)

Answer 33

1. Medicines must be in a suitable container that is properly labelled from the time they are produced until the patient uses them.
2. Throughout this time the container must maintain the quality, safety and stability of the medicine and protect it from the environment.

Question 34

What factors must be considered in relation to containers (5)

Answer 34

1. To enable good patient compliance, the container must be user friendly.
2. This is particularly important for elderly patients, so containers should be easy to open and re-close.
3. cost
4. the need for child-resistant closures
5. tamper-evident seals.

Question 35

What are sundry items (4)

Answer 35

1. medicine spoons
2. oral syringes
3. record cards, for example steroid or lithium cards are items
4. you will often give out with a dispensed medicine, especially when issuing medicines for children.

Question 36

what items may need storage in the fridge (6)

Answer 36

1. certain eye drops
2. creams
3. injections
4. insulin
5. Liquid antibiotics
6. need to be stored in the fridge to prevent them from spoiling.

Question 37

What advice must be given to patients in relation to storage (8)

Answer 37

1. not to store their medication in extreme temperatures, excessive light and moisture.
2. Unless the medication is required to be stored in the fridge, medications should be stored at room temperature.
3. Exposure to light can affect medicines, so patients should be advised to store their medicines away from direct sunlight.
4. Also recommend that medicines are not stored in the bathroom, because the high moisture levels in the air can degrade the drug and decompose the active ingredient.
5. Keep medicines in their original containers unless otherwise instructed by the pharmacist or the doctor.
6. Medicine containers are designed to protect the medicine against light, heat, oxygen, and microorganisms which all affect the stability of medicines. They also reduce the chances of the medicine being broken, damaged or reacting with the material of the storage container.
7. All medicines should be stored out of children’s reach and sight.
8. Bottles with child-resistant locks are provided for ensuring safety unless otherwise directed by the patient or GP and confirmed by the pharmacist, for example in patients with arthritis or some elderly patients who would find it difficult to open child-resistant locks.

Question 38

Where can you find expiry dates (3)

Answer 38

1. on the manufacturer’s packaging
2. or transferred onto the box if the medication has been broken down from the original packs.
3. Most medicines have a long expiry date but there are certain medicines that are given short expiry dates. For example, prepared antibiotics and eye drops.

Question 39

What are the expiry dates if prepared antibiotics (3)

Answer 39

1. After reconstitution with water, the stability of the medicine is changed.
2. It usually only lasts for 7 or 14 days, depending on the antibiotic
3. after which the product must be discarded

Question 40

What are the expiry dates of eye drops/ointments (5)

Answer 40

1. Most eye drops and eye ointments should be discarded 28 days after opening.
2. Eye drops contain preservatives, but once opened the preservatives can only ensure the product is safe for 28 days.
3. In order to prevent bacteria contaminating the eyes, eye drops/ointments should be discarded 28 days after opening as specified by the manufacturer.
4. Advise patients to record the date of opening on the packaging.
5. There are some eye preparations (eg Systane lubricating eye drops) available that can be used longer than 28 days – always check the packaging.

Question 41

Where can patients find the side effects (5)

Answer 41

1. Side effects can range from mild to severe and the risk varies from person to person.
2. The patient should be advised to read the patient information leaflet (PIL) for a full list of side effects.
3. Patients must be advised to speak to the pharmacist or their GP immediately if they experience any unusual or serious side effects.
4. On some occasions, the pharmacist or GP may decide to report the side effects to manufacturers of the medicine.
5. Certain medication can cause drowsiness and can make it unsafe to drive or operate machinery.

Question 42

What are the requirements for a delivery service (5)

Answer 42

1. That the dispensed items are safely and promptly delivered to the intended customer or carer
2. The delivery person must confirm the patient or carer’s identity before they hand over the prescription items
3. Any special storage requirements must be catered for for example a cool box in the vehicle for fridge lines
4. Records of delivery must be kept in the pharmacy for the request of the service, and each delivery or attempted delivery so the service can be monitored
5. Where possible the customer or the carer should sign to say they have received a delivery

Question 43

What are clinical trials (5)

Answer 43

1. In most countries, evidence of safety, quality and efficacy have to be provided to government regulatory bodies before a new drug can be launched and supplied to patients.
2. In the UK, the Medicines and Healthcare Products Regulatory Agency (MHRA) has to be satisfied with this evidence before a product licence is granted.
3. Clinical trials are used to test and assess medicines and provide the required evidence.
4. On the rare occasion, you may have to handle prescriptions for patients who are on a clinical trial.
5. You should treat such prescriptions as you would any other (unless your pharmacist tells you otherwise).

Question 44

What are the stages in a clinical trial (5)

Answer 44

1. Pre-marketing studies - Before a medicine can be tested on humans, it first needs to be tested for safety and effectiveness and this may be through testing on animals if no other alternative exists, to see if it will have any therapeutic benefits and/or if there are any possible toxic effects.
2. Phase I trials - The drug is tested on healthy adult volunteers.
3. Phase II trials - The drug is tested on small groups of target patients who may benefit from the trial drug.
4. Phase III trials - The drug is tested on larger groups of target patients who may benefit from the trial drug.
5. Post-marketing studies (Phase IV) - Ongoing monitoring of side effects associated with the drug once it is licensed and launched onto the market.