Prescription Writing Basics

1. Prescription Writing Basics Gordon 5/2014

2. Objectives • Discuss the different types and classes of medications • Discuss the importance of properly written prescriptions • Provide an overview of medication errors • Review the proper format for completing prescriptions • Practice calculating drug doses • Provide an overview of electronic prescriptions

3. Types of Medication • Regular • Viewed as non addictive or not habit forming • Controlled • Potential to create psychological or physical dependence • Over the counter (OTC) • Available without a prescription

4. Regular Medications • Must be prescribed by a licensed provider • Available only with a prescription • Limited quantities up to 1 year(includes refills) • Requires a completed prescription • Hand-written, call-in, or e-script • NPs may prescribe medications in 49 states (with and without limitations) • Several states have specific formulary requirements

5. Controlled Substances • Referred to as “scheduled drugs’ • Schedules I-V • Requires a DEA number and provider licensure to prescribe • 12 states and the District of Columbia allow NPs to prescribe controlled substances independently • 28 states require physician collaboration for prescribing controlled substance • 10 mention physician supervision in their guidelines

6. Controlled Substance Schedule I Schedule II Less risk for dependency than Schedule I Less likely to be abused than Schedule I drugs Cocaine, methadone, Dilaudid, Demerol, oxycodone, Fentanyl, Dexedrine, Adderall, etc. 1 month supply- no refills All hydrocodone products moving to this class Oct 1 2014. • High potential for abuse • Very likely to cause psychological and physical dependence • These medications have no acceptable use in the United States • Heroin, LSD, marijuana, ecstasy, methaqualone, and peyote

7. Controlled Substance Schedule III Schedule IV Low potential for abuse and or dependency Xanax, Valium, Talwin, Ambien, Ativan,Klonopin, Restoril, Ultram etc. Schedule III-IV drugs may have up to five refills allowed (6 month supply) May be given as a verbal prescription to the pharmacist • Lower potential for abuse than Schedules I and II • Codeine- up to 90 mg per dose; testosterone, ketamine, anabolic steroids, suboxone, etc. • For now *** Includes less than 15 mg of hydrocodone products in combination with other products such as acetaminophen (change 10/2014 to C-II)

8. Controlled Substance Schedule V • Lowest risk for abuse and dependency • Generally anti-diarrheal, antitussives, and pain management • Includes Lomotil, Lyrica, Robitussin AC • No limit on refills in a year period • However, monitor the number you are prescribing • May be faxed to pharmacy • Valid for 12 months from issue date

9. OTC Medication • May be written on a prescription • Can serve as a written reminder for the patient • May be covered by Health Savings Accounts • Medicaid has covered some OTC meds in the past • May be cheaper for generic versus OTC • Prilosec OTC versus omeprazole

10. Writing Prescriptions Correctly • Prevent patient injury or harm • Decrease costs of healthcare • Diminish risk of disciplinary action, license suspension, or revocation

11. Medication Errors • What is an adverse drug EVENT? • Harm or injury to a patient as a result of medication • Can be drug reaction • Even properly prescribed, allergic reactions may occur • May be the result of improperly written prescription (OCS Errors) • Error of omission • Error of commission • System error

12. OCS Errors • Omission • Failing to do something • Commission • Doing something WRONG • System • Not due to prescriber’s efforts • Drug name look a-likes and mix ups • Patient information- weight, pregnancy, etc. • Medication delivery device • Patient education

13. Most Common Errors • Indication errors • Under use or over use of medications • Dosing Errors • Trailing zeroes, illegible writing • Drug-Drug interactions • Not reviewing current medications • Inadequate Records • Lack of full disclosure of current medications • Misread or misinterpreted prescriptions

14. Avoiding Errors: The 5 Rights • Right patient • Right drug • Right dose • Right time • Right route

15. Avoiding Errors: Abbreviations Do Not Use… Write Instead… Write “unit” Written International Unit Write “daily” Write “every other day” Write “X mg” or write “0.Xmg” Write “morphine sulfate” or “magnesium sulfate” • U, u • IU • Q.D., QD, q.d., qd, • Q.O.D., QOD, q.o.d., qod • Trailing zero (X.0); lack of leading zero (.X) • MS, MS04 and MgS04

16. Components of a Hand-written Prescription • Prescriber’s Full Name and Address • Telephone number, license number, DEA number • Date Prescription is Written • Patient’s full name and address and/or D.O.B. • Legible Prescriber signature • Drug name, dose, dosage form, amount • Directions for use, indication • Refill instructions

17. Prescription Pad Requirements • All of the following items must be present in a prescription pad to be compliant with the “tamper resistant “ guidelines set forth by Centers for Medicare/Medicaid (CMS): • One or more features to prevent unauthorized copying • One or more features to prevent erasure or modification of information as written by the prescriber on the prescription • One or more features to prevent the use of counterfeit prescription forms

18. Examples of Tamper Resistant Changes • Background color should be blue or green with a design that is hard to reproduce • The paper should have an artificial watermark- this makes it difficult to erase or alter ink • The words "void" or "illegal" must appear when the paper is photocopied. • Heat sensors and watermarks that appear when the script is copied are options

19. Prescription “Void Appears When Copied”

20. E-Prescribing • Same information collected from patient • Name, DOB, weight, current meds, allergies, medical diagnoses, address, phone number, pharmacy of choice as well as health care coverage/insurer • Stored in electronic health record • Can be generated at office visit or for refills • Pharmacy receives prescription and processes for fulfillment

21. Points to Remember • Limit each prescription to one medication • Circle your name when using preprinted prescription pads • Approach medication names with caution • Eliminate confusing abbreviations • Use metric measures for dosages • Avoid writing “as directed” • Specify the therapeutic duration • Prescribe specific quantities rather than dispensing for time periods

22. Points to Remember • Remain cognizant of lethal doses of medications. • Choose dispense as written (DAW) if necessary • Double check your dosage • Quantity of pills to be dispensed (Avoid writing “Quantity Sufficient”) • Include the correct date • Include the correct route (by mouth, per rectum, etc) • Your signature • Mark your refills

23. Student Nurse Practitioners • As a student Nurse Practitioner, you are NOT permitted to prescribe medications • You cannot keep prescriptions that are signed by your preceptor and fill them out • You cannot be solely responsible for the plan of care

24. Prescription Writing Practice

25. Drug Calculations • Weight and age of patient • Convert pounds to kilograms: 2.2 pounds = 1 kg • Weight in pounds ÷ 2.2 = weight in kg • Concentration of oral suspension • Ex:400mg/ 5 ml • 400mg/5ml=80mg/1ml

26. Example 1 Jane Smith has hypertension and needs a prescription for Vasotec. She will take 5 mg, twice a day. It comes in 5 mg tablets. She will need a three month supply with refills for a year. Her address is 330 East First Street, Duluth, MN 55805.

27. Example 2 John Smith needs a prescription for eye drops. He uses one drop of Timoptic 0.5% in his right eye twice a day. It comes in 5 cc bottles. He needs three refills. Mr. Smith’s D.O.B. is 2/13/70.

28. Example 3 Jane Smith’s 12 year-old daughter Emily has asthma. She needs a three week course of tapering dose of Prednisone. She needs 40 mg per day for one week, then 20 mg per day for one week, then 10 mg per day for one week. It comes in 10 mg tablets. She should get no refills. She weighs 97 pounds and D.O.B. is 4/26/2002.

29. Example 4 John Smith has a broken arm and needs Norco for pain. It comes in 7.5 mg tablets. He should take one tablet every four hours as needed for pain. He needs thirty pills. No refills. His address is 4400 W. Grand Ave, Duluth, MN 55810.

30. Example 5 John Smith’s 2 month-old son Jimmy is diagnosed with otitis media. You want to prescribe Amoxil by mouth every 12 hours for 10 days. Amoxil suspension is available as 125mg/5mL. Jimmy weighs 12 pounds.  The safe dose is 30mg/kg per day. Jimmy’s D.O.B. is 04/24/2014.