Composing

Prescription
and
Referral
Deisy Radithia, drg. SpPM.
Oral Medicine Department
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Prescription & Referral

Letters only legal physicians have
the rights to write
Physicians = doctors, dentists, vets
Legal = certified, registered, licensed

Written instructions to our colleagues

Our colleagues = pharmacists, doctors & dentists
specializing in other disciplines, lab technicians

Be polite, do not appear authoritarian

Be careful with what you write down
May be used for medico-legal issues
You can be seriously sued when making
mistakes !!

What must be mentioned ?

1. Your identity & where you work
Physicians name & license number
Institution or Clinics name, address,
phone & office hours
Informing the recipients of how to
contact you again, just in case they
need to.
Your handwriting is unreadable
You order some bizarre drug name or dose
Your instruction is unspecific, ..etc..
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2. Date

Stating the exact date the instruction is

given

Informing the recipient of the exact date

you instruct the patient to see him
Patient feels better decides not to buy the
prescribed drugs one day, the symptoms
recur the old prescription = INVALID
prescription same symptoms same
disease
A patient suffering of an acute inflammatory
disease prescribed with a high-dose SAID
goes to the pharmacy 5 days later
INVALID prescription the inflammation

3. Your Signature

Sign your instruction briefly

Put your name & degree underneath
your signature

Validating your instruction

Prescription
Written instruction from a physician to a
pharmacist concerning the name, form
and dosage of a drug to be issued to a
certain patient
A communication medium
between physicians and pharmacists

Transparent, but concealed

Transparent not to be put inside a sealed
envelope
Concealed written in Latin codes & Roman
numerals
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How to make a
Prescription ?
1. Choose the right drug

The right diagnosis of the disease

The right drug group ~ regarding the
disease
The right form &dose ~ regarding the
patient
Allergic to certain substance ?
Patented or generic ?

2. Start Composing the Prescription

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Composing a Prescription
your ID & where you work top of the paper
Date
Drugs
Always begin with R/
1st line

Name
Quantity
Form caps.
Amount

Amoxycillin Povidon Iodine oral gargle

500 mg
1%
Fl.
no. XV 100 ml. no. I

2nd line
Dose 3 dd. I

coll. or.

Always end a drug with // & short signature next to

it

Patients identity
Name, Sex, Age in one line
Address at the 2nd line

Your ID &
where
you work
date

Prescrib
ed drugs

Deisy Radithia, drg., SpPM.

SIP No. 1234/PDGI/VI/2006

Oral Perfection Clinics Dr. Soetomo 83 Surabaya

5677596 Clinic hours: 16.00 20.00 WIB

Surabaya, 22 April
2008
R/ Povidon Iodine oral gargle 100 ml.
fl. No. I
u.c
//

R/ Amoxycillin 500 mg. caps. No. XV

And
Each drug is
3 dd I.
validated by
ended with
//
Your
patient
s ID

Pro
Alamat
204,

: Tn. Robert, 47 th.

: The Cosmopolis AKeputih Surabaya

Referral
A recommendation to consult other
professionals, from other disciplines
A communication medium
between physician and other physician

CONFIDENTIAL sealed envelope !!

It contains your patients condition in details
which must be respected and protected
Suspicion of diagnosis
Underlying systemic disease infection,
degenerative, neoplasm
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2 types of Referral
1. Seeking diagnosis
2. Seeking treatment

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Seeking diagnosis
Clinical diagnosis is based on
anamnesis & clinical examination
needs confirmation, by whats socalled Supporting Examination

Radiography
Imaging technique

Cytology
All about cell shape, count,

Histology
All about tissue tissue structure,

Molecular Analysis
Genomics & proteomics DNA, RNA, proteins,

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Note
Supporting examination is meant
to confirm a suspicion
Only refer when you have already
built up a clinical diagnosis
Refer to the right recipient
Have an expectation of several
conditions which might appear in
the result and be prepared with
several treatment plans
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Refer to the right recipient

Radiography
Radiology or Rntgen

Cytology
Micology & Bacteriology Microbiology
Blood, urine & stool Clinical Pathology

Histology
Tissue Biopsy Pathology Anatomy,
Surgery

Molecular Analysis
Expert in Molecular Biology
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How to compose?
Be polite
Briefly explain the patients
complaints & condition
Clearly state the intended
examination
Write down your suspicion or
clinical diagnosis
Be courteous Thank You
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Referring the patient or the

specimen ??
Referring the patient
Clearly state the location of the intended
examination and type of lesion

Referring the specimen

passed a training or workshop in various
biopsy technique? perform it yourself,
then simply send the specimen
Clearly state :
The original location of the specimen and type of
the lesion
Biopsy & fixation technique
transport media
Patients ID if your specimen is invalid, the
patient can be contacted to be re-biopsied
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Your ID

Deisy Radithia, drg., SpPM.

SIP No. 1234/PDGI/VI/2006

Oral Perfection Clinics Dr. Soetomo 83 Surabaya

5677596 Clinic hours: 16.00 20.00 WIB

recipient

date

Surabaya, 22 April 2008

Kepada Yth. TS. Dokter Bagian Patologi

condition
Anatomi
Patients
RSU Dr. Soetomo Surabaya
ID

What we
intend to
be done

Menghadapkan pasien Tn. Robert, 47 th,

dengan persistent oral ulcer tanpa rasa sakit.
Mohon dilakukan needle biopsy pada ulcer di
mukosa bukal sinistra posterior.
suspicio
Pasien dalam perawatan kami dengan
n
dugaan oral squamous cell carcinoma.
Atas bantuannya, terima kasih.
courtes
y

Wass. Kol.,

Your
signature

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Seeking treatment

When the disease needs to be treated

by other disciplines, because :

Totally irrelevant
Relevant, but the treatment belongs to
other disciplines
Relevant, but we do not possess the
necessary facilities

After being referred, the patient might

be :

totally dismissed from our care and receive

full treatment from other physicians
Receiving parallel treatment the disease
needs integrated therapy
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Giving up the patient to other physicians

If diagnosis decides that patient needs to
be treated by other physicians
Let it go we have limited knowledge,
different competence
Respect others
Talk it well with the patient
Do not lower your credibility !!

Compose a written referral to our

colleague
Include all patients medical record
Patients medical chronologic condition
Whatever we have done and given to the patient19

keyword
Mohon perawatan lebih lanjut di
bidang Sejawat

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Deisy Radithia, drg., SpPM.

SIP No. 1234/PDGI/VI/2006

Oral Perfection Clinics Dr. Soetomo 83 Surabaya

5677596 Clinic hours: 16.00 20.00 WIB

Surabaya, 22 April 2008

Kepada Yth. TS. Dokter Bagian Kesehatan
Kulit & Kelamin
RSU Dr. Soetomo Surabaya
Menghadapkan pasien Tn. Robert, 47 th,
dengan Syphilis stadium 2.
Pada pemeriksaan klinis didapatkan mucous
patches pada pangkal paha kiri, dan 2 bulan
yang lalu pasien mengalami ulserasi di
rongga mulut yang persisten & tidak sakit.
Pemeriksaan serologi Wasserman
menunjukkan hasil (+).
Mohon perawatan lebih lanjut di bidang
Sejawat.
Atas bantuannya, terima kasih.

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Treating the patient in parallel

If the disease manifests in the oral cavity
Diabetes, Hypertension, Syphilis, HIV-AIDS,
Allergy, Muco-cutaneous diseases, Cancer,
Refer to physicians in relevant expertise while giving
treatment for the oral lesions

If treatment in our discipline is complicated

by other conditions
Ulcer located near a sharp-edged tooth cavity
refer to Operative Dentistry or Oral &Maxillofacial
Surgery

Patient with Diabetes needs tooth extraction

refer to Internist to regulate blood sugar level before
procedure
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keyword
Penderita masih dalam perawatan kami
Or
Simply mention the treatment plan of your
discipline

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Deisy Radithia, drg., SpPM.

SIP No. 1234/PDGI/VI/2006

Oral Perfection Clinics Dr. Soetomo 83 Surabaya

5677596 Clinic hours: 16.00 20.00 WIB

Surabaya, 22 April 2008

Kepada Yth. TS. Dokter Bagian
Penyakit
Treatment
plan of
your discipline
Dalam
RSU Dr. Soetomo Surabaya
Menghadapkan pasien Tn. Robert, 47 th,
dengan Diabetes Mellitus.
Pasien datang pada kami dengan
periodontitis kronis akibat gangraen radix
gigi molar pertama bawah kiri, sehingga
perlu dilakukan ekstraksi gigi tersebut.
Mohon pemeriksaan kadar gula darah dan
perawatan pendahuluan di bidang Sejawat
yang sekiranya diperlukan.
Atas bantuannya, terima kasih.
Wass. Kol.,

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 Composing prescription & referral is

technically easy
Keep practicing practice makes
perfect
Just remember to be polite, brief &
specific
Do not give an impression of being
authoritarian
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Questi
ons ???
Deisy Radithia, drg., SpPM
081931542642
deisy_radithia@yahoo.com

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