drug chart writing lecture
TRANSCRIPT
Dr David Wood
Consultant Physician and Clinical Toxicologist
Guy’s and St Thomas’ NHS Foundation Trust,
London
How to write a drug chart
... properly!
LECTURE EXTRACT FOR PHASE
3
Key Steps in Prescribing
1. Ensure it is the right patient
2. Always write legibly
3. Sign and date everything you do
4. Check the allergy status before prescribing
anything
5. Check that you aren’t duplicating prescriptions
6. If are unsure ask about or look up doses,
frequencies and/or the drug you are prescribing
7. Take time when prescribing!
Area for patient
identification
Use hospital sticker
If no stickers then write:
– Name
– Date of Birth
– Hospital Number
ALLERGY SECTION
MUST BE FILLED IN
FOR EVERY PATIENT
BEFORE YOU WRITE
ANYTHING ELSE
Document what the
allergy is
Sign and date the entry
Don’t forget to alter
entry if patient develops
allergy
ONCE ONLY
PRESCRIPTIONS
Always date AND time
that you want drugs to be
given
First dose antibiotics
should be prescribed here
(Surviving Sepsis
campaign) – improves
number given within an
hour
ANTICOAGULANT
PRESCRIBING
Ensure you check the INR
result before prescribing
Warfarin
Be aware of the GSTFT
anticoagulant guideline on
how to correctly initiate
and continue Warfarin
therapy
Medicines Reconciliation
Nearly last page .....
but one of most
important
Ensure accurate drug
history prior to
admission
– GP
– Old letters (EPR)
– Pharmacy help
Drugs Not Given
Usually completed by
nursing staff
– Indicates reason(s)
for drugs not being
given
– Check on a regular
basis – is it because
your patient is “nil by
mouth”?
Regular Prescriptions:Key Components Part 1
Drug Name
Date of prescription
Dose
Duration of treatment
Route
Signature (AND NAME)
Check the patient’s name/allergy status first
Write legibly and preferably in block capitals
Use generic drug names not trade names
Dose and route have to legible
Sign and print you name for each prescription
Do not abbreviate micrograms and units
- Space between units and dose
Try not to use decimal points
Put a duration for drugs such as antibiotics
Key Components Part 1
Regular Prescriptions:Key Components Part 2
Pre-determine administration timesSpace to enter own times
Date for administration Area when administration is signed for
Check the patient’s name/allergy status first
Written legibly and preferably in block capitals
Clearly indicate times that you want drugs to be
given
- Tick times printed or legibly write times in
yourself
When crossing off medications
- Sign and date every time!
Regular Prescriptions:Key Components Part 2
As Required Prescriptions:
Drug Name
Date of prescription
Dose
Duration of treatment
Route
Signature (AND NAME)
Check the patient’s name/allergy status first
Check regular medication to ensure no
duplication
– E.g. Paracetamol and co-codamol
Write legibly and preferably in block capitals
Use generic drug names not trade names
Dose and route have to legible
Sign and print you name for each prescription
Do not abbreviate micrograms and units
As required prescriptions:Key Components
Re-writing of Drug Charts
Check all drug charts every time you
review your patients
Re-write charts yourselves
– You know the patient
– More time during the day than “out of hours”
Shouldn’t be an “out of hours job”
– Extra work for colleagues
– Increased risk of errors occurring
Summary
Prescribing is a complex process
Make yourself familiar with the drug chart(s)
used where you are working
Take time when prescribing
Try to ensure you minimise the risk of errors
in the prescribing pathway occurring
Know sources of advice and help when you
are prescribing