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Prescription Writing 101Gail Feinberg, DO, FACOFPOctober, 20091ObjectivesUnderstand what makes a prescriptionIntro to Latin abbreviationsIntro to DEAPractice writing prescriptions

2The parts of a prescriptionWhat is a Prescription?A prescription order is written for diagnosis, prevention or treatment of a specific patient's diseaseIs written by a licensed practitionerIs written as part of a proper physician-patient relationshipIs a legal document, "prima facie" evidence in a court of law.(side noteA prima-facie case is a lawsuit that alleges facts adequate to prove the underlying conduct supporting the cause of action and thereby prevail.)

4DefinitionLiterally, "Recipe" means simply "Take...." and when a medical practitioner writes a prescription beginning with "", he or she is completing the command. Was probably originally directed at the pharmacist who needed to take a certain amount of each ingredient to compound the medicine (rather than at the patient who must "take/consume" it).5DefinitionThe word "prescription" can be decomposed into "pre" and "script" and literally means, "to write before" a drug can be prepared. Another theory exists that the "" may have originally been a "Px", where the "P" is short for "pre", and the "x" is short for "script".

Parts of the PrescriptionPatient InformationSuperscriptionInscriptionSubscriptionSignaDateSignature lines, signature, degree, brand name indicationPrescriber informationDEA# if requiredRefillsWarnings/label

7Patient InformationName AddressAge Weight (optional, but useful - esp in peds)Time (used only with inpatient medication orders)8SuperscriptionRXTraditional symbol for prescriptionUse it to line up the other parts of the Rx

9InscriptionWhat is the pharmacist to take off the shelf?Drug NameDose = Quantity of drug per dose formDose Form = The physical entity needed, i.e. tablet, suspension, capsuleSimple vs. Compound PrescriptionsManufactured vs. compounded prescriptionsClarity of number forms 0.2, 20 not 2.0 (Zeros lead but do not follow!)

10SubscriptionWhat is the pharmacist to do with the ingredients?Quantity to be dispensed (determines amount in bottle) Dispense # 24 For controlled substances write in numbers and letters (like a bank check)#24(twenty four)Any special compounding instructions

11Signa, Signatura or TranscriptionSigwrite, or let it be labeled (Latin terms: signa or signetur)Instructions for the patientRoute of administrationOral, nasally, rectally, etcTake by mouth.., Give, Chew, Swallow whole, etc.Number of dosage units per doseTake one tablet, Give two teaspoonfuls, etc.Frequency of dosingevery six hours, once a dayDuration of dosingfor seven days,... until gone, ...if needed for pain.Purpose of medication for pain, for asthma, for headache, etc.VERY IMPORTANT to include purpose as this reduces errors!Do not use As directedSpecial instructions (shake well, refrigerate etc.)Warnings12Refills and Date PrescribedIndicate either no refills or the number of refills you want (dont leave it blank) Determines maximum duration of therapy.Date the prescriptionAll prescriptions expire after one yearSchedule II drugs can only be dispensed within 7 days of date on RXCV-CIII can be refilled for 5 time in 6 mo. maximum.Automatic Stop Orders (inpatient orders)Antibiotics-7 daysControlled Substances-3 days

13Signature of PrescriberThis makes the prescription a legal documentInclude your degreeYou must write brand necessary, brand medically necessary, or DAW (Dispense as Written) to get non-generics.

14DEADEA (if required)All medical prescribers are required to request and receive a DEA number, which contains two letters, six numbers, and one check digit before a single narcotic prescription can be dispensed. This is a precaution taken by the DEA to ensure that controlled substances are being prescribed by only qualified professionals.

16DEA Number detailThe first letter in the code is the type of practiceA DeprecatedB Hospital/ClinicC PractitionerD Teaching InstitutionE ManufacturerF DistributorG Researcher H Analytical LabJ ImporterK Exporter

L Reverse DistributorP- Narcotic Treatment ProgramR Narcotic Treatment ProgramS Narcotic Treatment ProgramT- Narcotic Treatment ProgramU Narcotic Treatment ProgramX Suboxone/Subutex Prescribing Program

17DEA Number detailThe second letter is the initial of the practitioners last name. The third, fourth, fifth, and sixth numbers are randomly selected by a computer. The check digit is a calculation of the following:Addition of the first, third and fifth digitsAddition of the second fourth and sixth digits times twoAdd the sums of the two numbersThe sum is the last digit18Latin abbreviationsLatin Used in Prescription WritingAbbreviationLatinMeaningbidBis in dieTwice dailytidTer in dieThree times dailyqidQuarter in dieFour times dailyhs (or qhs)(Quaque) hora somniAt bedtime (each night)pcPost cibumAfter meals (or not on an empty stomachprnPro re nataAs circumstances may requirepoPer osBy mouth (orally)prPer rectumRectally (suppository)ac Ante cibumBefore mealsgtt (gtts)GuttaeDrop(s)20Latin Used in Prescription Writingfile:///C:/Documents%20and%20Settings/Gail%20Feinberg/Desktop/List_of_abbreviations_used_in_medical_prescriptions.htmfile:///C:/Documents%20and%20Settings/Gail%20Feinberg/Desktop/List_of_medical_abbreviations%20_Do-not-use_list.htm

21Preventing Medical ErrorsAvoiding Medical ErrorsPrescribing incorrectlyCan be due to slips, lapses or lack of knowledge (mistakes) (Always check dosage calculations!!!!!!)Using ambiguous symbolsPoor handwriting

23Avoiding AmbiguityCareful use of decimal points to avoid ambiguity: Avoiding unnecessary decimal points: a prescription will be written as 5 mL instead of 5.0 mL .Always using zero prefix decimals: e.g. 0.5 instead of .5 to avoid misinterpretation of .5 as 5.Avoiding trailing zeros on decimals: e.g. 0.5 instead of .50 to avoid misinterpretation.Avoiding decimals altogether by changing the units: 0.5 g is less easily confused when written as 500mg.mL" is used instead of cc" or "cm" even though they are technically equivalent to avoid misinterpretation of 'c' as '0' or the common medical abbreviation for "with" (the Latin "cum"), which is written as a 'c' with a bar above the letter. Directions written out in full in English Quantities given directly or implied by the frequency and duration of the directions.Where the directions are "as needed", the quantity should always be specified.

24Avoiding AmbiguityWhere possible, usage directions should specify times (7 am, 3 pm, 11 pm) rather than simply frequency (3 times a day) and especially relationship to meals for orally consumed medication.The use of permanent ink.Avoiding unspecified prn or "as needed" instructionsinstead, specific limits and indicators are provided e.g. "every 3 hours prn pain."For refills, the minimum duration between repeats and number of repeats should be specified.Providing the indication for all prescriptions even when obvious to the prescriber, so that the pharmacist may identify possible errors.Avoiding units such as "teaspoons" or "tablespoons."

25Avoiding AmbiguityWriting out numbers as words and numerals ("dispense #30 (thirty))The use of apothecary units and symbols of measure is discouragedpint (O), ounce (), drams (), scruples (), grains (gr), and minims () Given the potential for errors, metric equivalents should always be used.The use of the degree symbol (), which is commonly used as an abbreviation for hours (e.g., "q 2-4" for every 2 - 4 hours), should not be used, since it can be confused with a '0'. In addition, the use of the degree symbol for primary, secondary, and tertiary (1, 2, and 3) is discouraged, since the former could be confused with quantities (i.e. 10, 20 and 30, respectively).

26Prescription SecurityTo prevent copying of prescription/padAnti-copy Watermark. By tipping the paper towards the light, a picture appears to verify that the prescription is an original. Usually a Rx appears. Anti-Coy Coin Rub.By rubbing a penny across the back of the prescription the words Secure Prescription Paper appears.Hidden Message Technology. The word Void appears if a copy is made.

27Prescription SecurityTo prevent modification of prescriptionToner Bond Security. The paper is treated with a compound that fuses with any ink used on it (including toner from printers). Blue Security Background. Prevents erasing of prescription.

28Prescription SecuritySecurity measures to prevent counterfeiting of prescription formsUnique Production Batch Numbers. Unique numbers are assigned to every printed batch by the manufacturer. Security Warning Band. Visible warning band provides warning of security measures on paper to prevent counterfeiting UV Fiber Secure. Invisible fluorescent fibers and threads that can only be seen under blacklight While some physicians use printers and a specific program to write their prescriptions, the same strict guidelines are used in the design of the printer paper used for prescriptions as well.

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30Practice ProblemsPractice #1Write a prescription for Amoxil, which can be given either 125mg/5mL or 250mg/5mL to a child who is 45 lbs (approx 20kg). The dose is 20-40mg/kg/day divided into 3 doses per day. Child needs to be on the antibiotic for 10 days32Prescription should sayAmoxil 250/5mlDisp: 150mLSig: 5mL tid until gone33

Denise WatermarkOct. 6, 2009Amoxil 250/5mlDisp: 150mLSig: 5mL tid until gone (also acceptable is 5mL tid x 10 days)

Gail Feinberg, DO, FACOFPnonePractice #2Jane Doe need refill of her digoxin. Her dose is 1.25mg daily and she takes one daily. She needs a 30 day prescription to take to the pharmacy today and another one for 3 months to mail offwrite both for her.3530 day will look likeJane DoeDigoxin 1.25 mgDisp: #30Sig: One p.o. daily (here can also add for CHF or whatever appropriate)No refill36

Jane Doe10/7/09Digoxin 1.25mgDisp # 30Sig: One (1) po daily (can also add for CHF)90 day will look likeJane DoeDigoxin 1.25 mgDisp # 90Sig: One p.o. dailyNo refill38

Jane Doe10/7/09Digoxin 1.25mgDisp # 90Sig: One (1) po daily (can also add for CHF)Practice #3Tom Smith has pulled his back out and you are going to give him some Flexeril (Cyclobenzaprine) as a muscle relaxer. This is given as 10mg up to three times daily as needed for muscle spasm. You only want to give him at most a weeks worth.

40Prescription should look like..Tom SmithFlexeril 10mg# 21 (twenty one)i p.o. up to tid prn muscle spasm(note the irepresents one ii=2, iii=3, iiii or iv = 4 etc.)Can also write one (1) po up to 41

Tom Smith10/7/2009Flexeril 10mg DAW#21 (twenty one)1 po up to tid prn muscle spasmCaution: May cause drowsinessnone