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Subject: Pharmacology Topic: Intro to Prescription Writing Lecturer: Dr.

Dela Cruz Date of Lecture: Transcriptionist: Pages:

When a patient comes to a doctor, an encounter happens, this encounter would lead to certain stages. -> would eventually end up in a prescription of medication or intervention that is meant to alleviate the patient s condition. Hallmark of the profession -> writing a prescription. Prescription comes from the word prescribe (you are given something) y a written order or instruction of a validly registered prescriber to a dispenser for the use of a specific drug product for a specific patient o usually written but now can be given verbally or it can be electronically generated. a legal document o therefore all the requirements for a legal document should be there can be computer generated specially in the US

y y y

The right date, number of refills because not all prescriptions need to do a refill The correct duration of treatment The right to informed consent- inform the patients on the medication/drugs you intend to prescribe the patient o You have to spend some time with your patient. The right to refuse treatment- the patient can refuse treatment after you have explained what is necessary o Has the option to accept or refuse the treatment o Patient has also the right to seek another opinion, so do not be hurt or insulted when a patient seeks a 2nd opinion because it s a right.

As doctors, it is a responsibility to prescribe the most appropriate, best recommended, most suitable drug for the patient. y Important to know what you are prescribing.

When a patient comes to a physician, y A patient physician encounter usually results in a prescription o If there is no prescription,  patients feel that their visit to the physician is not completed or fulfilled physicians feel that they have not fulfilled their role if the patient is not issued a prescription

PRESCRIPTION WRITING OBJECTIVES *Correctness of Form 1.) Simple a. There should only be one drug per prescription i. First mentioned in Generic Act of 1988 but is amended such that it now allows more drugs in a prescription but for SIMPLICITY just one drug per prescription. 2.) Neat a. No erasures, no unnecessary marks, the paper you re going to use should be clean b. Neatness also speaks of your personality 3.) Legible a. If you re a doctor, it doesn t give you a right for an illegible handwriting. b. a legible handwriting speaks of the writer s willingness to communicate i. if it can t be understood, how can you communicate?

The RIGHTS of a prescription: y y y y y The right patient The right drug The right dosage amt to be administered The right dose The right route of administration the best route that is most suitable for the condition

SY 2011-2012

ii. Writing is a form of communication c. to avoid medication errors d. It is the legal duty of a Physician to write legibly i. Some deaths have already resulted because of wrong interpretation of an illegibly written prescription Sample Handwriting of a Physician

Prescribed: Avandia: an anti-diabetes Interpreted: Coumadin: an anticoagulant. Results y y

drug y

failure to take the drugs for diabetes (blood sugar increased tremendously) since Coumadin: anticoagulant can cause bleeding effect can be fatal

4.) Written in ink a. The ink has to be blue or black b. It s a medico-legal document i. Contract between a patient and a doctor c. Erasures on a prescription can easily lead to dispensing errors or abuse of controlled substances i. Will not be accepted by the drugstore because it is suspicious of tampering especially for controlled substances 5.) Provide precise, clear and specific directions a. Clear to the patient i. To avoid medication error ii. Most important should be given first 6.) Use of Generic Name a. Mandated by law (Generics Act of 1988) Three Names by which a Drug is Known y Chemical Name o Exact chemical derivation/ composition of drug o Not suitable for prescription o Ex. N-acetyl-p-aminophenol (Paracetamol) Generic Name o Also called as official or nonproprietary name

nobody owns the generic name o given by an official agency  e.g. World Health Organization o based on the chemical name  commonly, sounds like the chemical name but is shortened o scientifically and internationally recognized active ingredient of the product o names are decided by the World Health Organization (WHO) o Ex. Paracetamol (U.S.P.) or Acetaminophen (B.P.) Brand name/Trade name/ Trademark o commercial property of a pharmaceutical company that manufactures the product  (same chemical, same drug)  Name given to a drug to distinguish it as being a manufacturer s product o also called as Proprietary name  Registered trademark - o Company spends enormous amount of money in its promotion  Claims it as their own so they promote it as their product  Manufacturer assumes quality and consistency of the product  Drugs with brand names are more expensive than drugs with generic name o Ex. Biogesic, Tempra, Calpol, Tylenol

Advantages of Using the Generic Name 1. Universality o proprietary names differ from country to country o a drug would only have one Generic name (even if you go to different countries) o avoids duplication 2. Clarity o gives information to which class the drug belongs  nomenclature o group similarities are immediately apparent o e.g.  Beta blockers ( olol) y Propranolol, Metoprolol, Acebutolol

Penicillin (-cillin) y Amoxicillin, Ampicillin

ii.

3. Economy o o Cheaper, less expensive usually but not always

iii.

iv. 4. Convenience o allows substitution  allows the pharmacist to supply whatever version of the drug is in stock  allows cheaper drug to be chosen Disadvantages of Using the Generic Name 1. Difficult to spell or recall e.g. Carboxymethylcysteine/Carbocysteine (Solmux, Loviscol) o Too long 2. Questioned Therapeutic equivalence/ Therapeutic inequivalence o quality of generic drugs o perception that generic drugs are less effective than branded ones. o task of duly constituted authorities to assure that generic and branded medicines are pharmaceutically and biologically equivalent  all drugs passes through BFAD, therefore all quality control has been done to assure that the products are of good quality. Correctness of Form (cont.) 7.) Written in English or the language best understood by the patient a. It should be understood by the patient 8.) Capitalization of appropriate letters a. First letter of the name of drugs and dosage form b. T in Tablet, S in Syrup should be capitalized, no need to capitalize all letters 9.) Correct spelling and grammar 10.) No abbreviations a. source of miscommunication b. errors in interpretation (subject to different interpretations) c. substitution of drug with converging names but with divergent effects (errant substitutions) e.g. i. Isordil for angina ii. Iselpin for peptic ulcer d. Dose distortions e.g. i. cc could be misinterpreted as c.c. (cum cibum - with meals)

gr. for grain can be confused with gram  large dose difference Use of the degree symbol () for hours (every 4) or for primary (1) o.d. for once a day, may be interpreted as for the right eye

*Precision in Dosage y Use of Metric System of weights and measures o weights: grams, mg, micrograms o volume: ml (not cc), liter o if it s more than 1 gram = write gram o if it s less than 1 gram = write mg o if it s less than 1 mg = write mcg  mcg not g should be used for microgram Units of the metric system is preferred instead of household measures (e.g. dropperful, teaspoonful, etc) o If you use them be sure that the teaspoon is equivalent to 5ml because usual teaspoons are only 4ml. o Tablespoon should be 15ml to ensure precision because usual tablespoon is only 10ml. Use of calibrated droppers provided by the manufacturer or use standard dropper issued by pharmacist. o For every ml, 20 grams. Use Arabic rather than Roman numerals o Since the prescription is in English, use Arabic numerals. If there is a decimal point, o which preceeds the number, you put a 0 before the decimal point - (leading Zero)  to emphasize the position of the decimal point  e.g. 0.2 o Never use trailing zero s  e.g. 2.0 y You do not need to put a decimal point. Variation in dosage is allowed for as long as you don t exceed 10% (exemption in variation : very potent drug comes in mcg) o 513 mg p 500 The number of prescribed drug should match the number expected based on the duration of treatment Dispense in specific quantities o Do not prescribe 10.5 tablets; if you need an added 0.5, then you use 11 instead of 10.5. o When they come in liquids, utilize the volume of the bottle that is closest to the total required volume. *Should be more rather than less. so that it is enough for the duration of treatment

Prescribe only the specific no. of doses until follow-up o So that the patient will comply with follow-up appointments, to check if he/she is responding to the treatment

Requirements for Precision in Dosage: y Usual dose y Size of the available preparation or strength of the preparation y Frequency of administration o based on 16 waking hours if it is not noted to be taken round the clock.  if the instruction is to take the table every 4 hours, it is based on 16 waking hours (4 times a day) o round the clock (24 hours) if the instruction is to take the table every 4 hours round the clock, then you have to have 6 doses. y Duration of treatment o So you d know the total number to be dispensed. PARTS OF THE PRESCRIPTION 1. Superscription Name of patient & Address  for identification and record keeping purposes  to insure or assure that the correct medication goes to the correct patient AN IMPORTANT CAVEAT p Do not write a prescription for someone you have not seen. p Remember that no clinician-patient relationship is established when the patient is not seen. Age  a requirement in pediatric and elderly patients  to insure the appropriate use of drug and dose  avoid age-inappropriate prescriptions p For medications whose dosage involves calculations, the patient s weight or body surface area should also be listed Date  a medico legal document  establishes the temporal relationship between patient-physician encounter and the time the prescription is filled  monitor compliance behaviors  recognizing potential problems

Symbol  symbol for medical prescription  without Rx, it is not a medical prescription **not exactly Rx but an R with a tail and a bar crossing it  has three possible derivations:  Eye of Horus  Sign of the planet Jupiter  abbreviation for the Latin word recipere The symbol Rx is derived from the major lines in the symbol of the Eye of Horus. The Egyptians considered it a symbol of good and restored health. The sign of the planet Jupiter; as such it was placed upon horoscopes and upon formula containing drugs made for administration to the body, so that the harmful properties of these drugs might be removed under the influence of the lucky planet. Rx is an abbreviation for the Latin word recipere, which means to take or take thus.

2. Inscription body  Generic name of the drug  Clearly indicated dosage form  e.g. Tablet, Capsule, Syrup, Solution for Injection  Size of the available preparation (tablet) or strength/concentration of the preparation (liquid)  e.g. 500mg tablet, 250 mg/5 ml., 2% 3. Subscription  direction to the dispenser > Pharmacist  contains the total quantity to be dispensed based on the frequency of administration and the duration of treatment  written as Dispense no. total amount to be dispensed  Do not substitute # for no.  should be the appropriate quantity for the full course of treatment 4. Signatura / Label  direction to the patient  patient and drug specific  preceded by the word Label or Sig.  Starts with the manner or route of administration: Take (oral) Give (pediatric/if person cannot take the drug by himself) 4

 

Instill or place (drops) Apply (topical) Insert (suppositories) For injection (parenteral) simple directions  must be clear and concise  in language that is best understood by the patient, should be brief but precise instruction on when and how to take medications Do not use the phrase Take as directed or A.D. because it often leads to:  Non-compliance  Patient confusion  Medication error

p ILLEGAL drugs: Heroin, Methylene dioxymethamphetamine (MDMA) or Ecstasy, Lysergic acid diethylamide (LSD), Mescaline Schedule II  high potential for abuse  some has a currently accepted medical use  abuse of substance may lead to severe psychological and physical dependence  prescription of these drugs are limited, CANNOT be refilled p morphine, codeine, and opium p hydromorphone, methadone, meperidine (pethidine), oxycodone, and fentanyl p amphetamine, methamphetamine, dextroamphetamine, methylphenidate, cocaine, amobarbital, glutethimide, and pentobarbital Schedule III  abuse potential less than Schedule I and II substances  has a currently accepted medical use  abuse may also produce dependence  refills are allowed if authorized in the prescription  may be refilled up to 5 times within 6 months after the date when the prescription was issued p Anabolic steroids (used by athletes to enhance their performance) p Vicodin ni Dr. House Schedule IV  abuse potential less  has currently accepted medical use  abuse of substance may lead to limited dependence relative to substances in schedule III p IV narcotics i.e. propoxyphene p Alprazolam, clonazepam, clorazepate, diazepam, lorazepam, midazolam p Zolpidem

p Dose how much of the drug is to be taken  e.g. 1 tablet p Frequency of administration how often  e.g. every four hours p Duration of treatment to be able to compute for total amount to be dispensed  e.g. for 5 days, for 7 days p Specify the indication - encouraged  reminds the patient of the drug s purpose  confirm to the pharmacist the appropriate medication p Special instructions or Warnings  Non- refillable or for refill  Take with food  Shake well before using 5. Prescriber s Data  Name and Signature  Initials M.D. after the prescriber s name  License no. / PRC no.  PTR no. Professional Tax Receipt No.  S2 or Opium license no. (if you re prescribing controlled substances) p Use your own name + MD in writing Rx otherwise you prescription will be entirely wrong (for exam purposes also ) p Your signature signifies your full liability of the prescription At this point in your life, you will now practice to write or attach the initials MD after your name. You have to get used to the fact that eventually you re going to be doctors and you will have that MD sign after your names. Dr. Delacruz SCHEDULE OF CONTROLLED SUBSTANCES Schedule I  high potential for abuse  NO accepted medical use or lacks accepted safety profile if used for treatment  may be used for research purposes by properly registered individuals

Schedule V  Buprenorphine p products containing a low dose of an opioid plus a non-narcotic ingredient, e.g.: p Codeine (low dose opoid) + Guaifenesin (non-narcotic ingredient) as cough syrup cough preparation contains not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC)

 

p Diphenoxylate (present in small amount in Lomotil) plus atropine for diarrhea lower potential for abuse relative to substances listed in Schedule IV consist primarily of preparations containing limited quantities of certain narcotic and stimulant drugs generally used as antitussive, antidiarrheal and analgesic

reaction, you will not be legally liable because you did the skin test. How to do a skin test: You have to reconstitute the preparation. y y y Get the vial, add 1.5ml (so it s liquid already). Then get 0.1ml of that, then add 0.9 ml distilled water. Use a tuberculin syringe, then inject at the forearm intradermally (just beneath the dermis), 10-25 degrees angle of the needle. o Amount to be injected: just enough to do a 1cm wheal. Mark the borders of the wheal with a ball pen then observe for 30 minutes. o It is positive if there is redness, swelling, itchiness beyond the marked borders of the wheal When the result is equivocal (you cannot say it s positive or negative, there is swelling but did not go out of the borders), in the other arm, make another wheal from the same solution then 2 inches away from the site, you do a negative control, use a distilled water and make another wheal then observe for 30 minutes. Legal implication if the skin test is negative and after administering the drug the patient developed an allergic reaction, the physician is not liable because the skin test is not 100% reliable.

Prescription for a controlled substance must include the following information:  Date of issue  Patient's name and address  Practitioner's name, address, and S2 number  Drug name, strength and dosage form  Quantity prescribed  Directions for use  Number of refills (if any) authorized  Manual signature of prescriber Types of Defective Prescriptions: 1. Violative Prescriptions Generic name is not written Generic name is not legible , brand name is legibly written Brand name is indicated and an instruction such as no substitution is added 2. Erroneous Prescriptions Brand name precedes the generic name Generic name is the one in parenthesis Brand name is not in parenthesis 3. Impossible Prescriptions Only the generic name is written but not legible Generic name does not correspond to the brand name Both the Brand name and Generic name is not legible Drug product is not registered with BFA Parenteral Drugs & Skin Test y y Use parenteral for emergency situations. Not all parenteral drugs use skin test, there are inject only after negative skin test . o Exemption (does not need skin test): drugs that are used for life threatening conditions. If the preparation is likely to cause an allergic reaction, like an antibiotic, you need to do a skin test. Legal implications, if the skin test is negative, then you give the drug and it gives an allergic

Sample Prescription: Solid, oral Nikky Javier Silang, Cavite Superscription Aug. 7, 2009

Paracetamol Tablet 500 mg Dispense no. 12 Sig: Take one tablet every 4 hours, as necessary for 3 days. Ma. Luisa D. Delacruz, M.D. PRC Lic. No. 49339 PTR no. 2345680

Inscription Subscription Signatura

Prescriber s data

as necessary p Include in prescribing drugs for symptomatic relief only p Do not include in prescribing for definitive treatment Sample Prescription: Liquid, oral Nikky Javier, 8 yrs old Silang, Cavite Superscription Aug. 7, 2009

Paracetamol Syrup 250mg/5ml Dispense no. 1 bottle (60 ml) Sig: Take one teaspoonful every 4 hours, as necessary for 3 days. Ma. Luisa D. Delacruz, M.D. PRC Lic. No. 49339 PTR no. 2345680

Inscription Subscription Signatura

Prescriber s data

*1tsp (5ml) x 4hrs = 20 x 3days = 60ml Sample Prescription: Liquid, parenteral Nikky Javier, 8 yrs old Silang, Cavite Superscription July 27, 2011

Paracetamol Solution for Injection Dispense no. 12 ampules

150mg/ml

Inscription Subscription Signatura

Sig: For Injection. Inject 1 ml intramuscularly every 4 hours, as necessary for 3 days. Ma. Luisa D. Delacruz, M.D. PRC Lic. No. 49339 PTR no. 2345680

Prescriber s data

Nikky Javier, 8 yrs old Silang, Cavite

Superscription July 27, 2011

Amoxicillin for Injection Dispense no. 20 vials

500 mg

Inscription Subscription

Sig: For Injection. Dissolve the contents of 1 vial in 1.5 ml distilled water and inject intravenously every 6 hours round the clock. Inject only after a negative skin test. Ma. Luisa D. Delacruz, M.D. PRC Lic. No. 49339 PTR no. 2345680

Signatura

Prescriber s data

Remember: dissolve the contents of the vial, not the vial! INJECT ONLY AFTER A NEGATIVE SKIN TEST indicated in the prescription if the preparation can induce an allergic reaction. (see part on HOW TO DO A SKIN TEST)

END TRANSCRIPTION

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