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Prescriptions

Prescriptions. Catherine A. Marco, MD, FACEP. Goals & Objectives. Describe the proper physician-patient relationship Describe clinical decision making regarding medication prescriptions Delineate the basic components of a written prescription. The Physician-Patient Relationship.

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Prescriptions

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  1. Prescriptions Catherine A. Marco, MD, FACEP

  2. Goals & Objectives • Describe the proper physician-patient relationship • Describe clinical decision making regarding medication prescriptions • Delineate the basic components of a written prescription

  3. The Physician-Patient Relationship • Patient identification • Establish diagnosis • Treatment plan, options, counseling • Follow-up care • Online or telephone evaluations are not adequate • A pharmacy may not fill a controlled substance prescription in the absence of a proper physician-patient relationship

  4. Prescription • A prescription order is written for diagnosis, prevention or treatment of a specific patient's disease • Is written by a licensed practitioner • Is written as part of a proper physician-patient relationship • Is a legal document, "prima facie" evidencein a court of law.

  5. Over-The-Counter -OTC • Patient can use drug safely by reading the labeling instructions. • Examples • analgesics like aspirin and ibuprofen • topical antibiotics • Cough and cold remedies • Some vitamins

  6. Rx Only Drugs • Can only be dispensed on a prescription order • Synonyms: Legend (or dangerous) • Physician training required to use safely • Examples • Most systemic antibiotics • Cardiovascular drugs • Most drugs that have dependence liability

  7. Controlled Substances • Drugs with abuse potential • Classification CI, CII, CIII, CIV, CV • Schedule III,IV, V are obtained on a regular prescription • Must include date • Must include prescriber DEA# • Schedule II drugs require an “official” Rx form • (formerly used a “triplicate Rx”) • Schedule I, some drugs (chemicals) may not be available by any legal means • Heroin • LSD

  8. Schedule I • The drug or other substance has a high potential for abuse. • The drug or other substance has no currently accepted medical use in treatment in the United States. • There is a lack of accepted safety for use of the drug or other substance under medical supervision. • Some Schedule I substances are heroin, LSD, marijuana, and methaqualone.

  9. Schedule II • The drug or other substance has a high potential for abuse. • The drug or other substance has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions. • Abuse of the drug or other substance may lead to severe psychological or physical dependence. • Schedule II substances include morphine, PCP, cocaine, methadone, and methamphetamine.

  10. Schedule III • The drug or other substance has a potential for abuse less than the drugs or other substances in Schedules I and II. • The drug or other substance has a currently accepted medical use in treatment in the United States. • Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence. • Anabolic steroids, codeine and hydrocodone with aspirin or Tylenol, and some barbiturates are Schedule III substances.

  11. Schedule IV • The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule III. • The drug or other substance has a currently accepted medical use in treatment in the United States. • Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule III. • Included in Schedule IV are Darvon, Talwin, Equanil, Valium and Xanax.

  12. Schedule V • The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule IV. • The drug or other substance has a currently accepted medical use in treatment in the United States. • Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule IV. • Over-the-counter cough medicines with codeine are classified in Schedule V.

  13. Parts of the Prescription • Rx (an abbreviation for "recipe," the Latin for "take thou.“) • Superscription (Patient Information) • Inscription • Subscription • Signa • Date • Signature lines, signature, degree, brand name indication • Prescriber information • DEA# if required • Refills • Warnings

  14. Patient Information • Name • Address • Age (Required on triplicate or “official”) • (30y/o) • Weight (optional, but useful) • Time-(inpatient medication orders)

  15. Inscription • What is the pharmacist to take off the shelf? • Drug Name • Dose = Quantity of drug per dose form • Dose Form = The physical entity needed, i.e. • tablet, suspension, capsule • Simple vs Compound Prescriptions • Manufactured vs compounded prescriptions • Clarity of number forms 0.2, 20| not 2.0 • (Zeros lead but do not follow!)

  16. Subscription • What 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

  17. Signa, Signatura or Transcription • Instructions for the patient • Route of administration: Oral, nasally, rectally, etc • Take by mouth.., Give, Chew, Swallow whole, etc. • Number of dosage units per dose • (Take one tablet, Give two teaspoonfuls, etc). • Frequency of dosing (every six hours, once a day, etc.) • Patient lifestyle, inpatient schedules (compliance) • Duration of dosing (...for seven days,... until gone, ...if needed for pain). • Purpose of medication for pain, for asthma, for headache, etc. • Avoid “As directed” • Special instructions (shake well, refrigerate etc.) • Warnings

  18. Refills and Date Prescribed • Indicate either no refills or the number of refills you • want (don’t leave it blank) • Date the prescription • All prescriptions expire after one year • Schedule II drugs can only be dispensed within 6 months of date on RX

  19. Signature of the Prescriber • This makes the prescription a legal document • Include your degree • One signature line • You must write “brand necessary” or “brand medically necessary” to get non-generic agent. • Electronic Rx’s coming!

  20. D.E.A. Registration Number • Drug Enforcement Agency (DEA)-US Government • Also enforced by Texas Dept. Public Safety (DPS) • DEA# is needed on any controlled substance (CII-CV)

  21. Communicate Before YouMedicate! • Tell patient the name of the drug and what it is for. • Tell your patient exactly how to use the medication • Warn them of possible problems • What to do if dose is missed • Cost (source?) and storage • Review Rx for possible for errors

  22. Common Abbreviations • qd or od = every day • qod = every other day • bid = twice daily • tid = thrice daily • qid = four times/day • ac = before meals • pc = after meals • hs or qhs = at bedtime • disp = dispense • prn = as needed • po = by mouth (orally) • IV = intravenous • IV push or bolus = at one time • IV infusion = infuse over time • IM = intramuscular • stat = immediately • sq or sc = subcutaneous • sig = signa or signetur = directions for use

  23. Qod and qid can get mixed up; qod and qd can get mixed up. • One solution is to write out “once a day” or “once every other day” or “four times daily.” • This brings up the confusion between q6h and qid. • Does this medication require a strict 6-hour dosing interval? • Or, can it be given four times daily, for example, in a 6:30 AM to 11:00 PM day?

  24. Telephone Orders • Telephone orders may be placed for drugs in Schedules III, IV, and V. • A written prescription is required for ordering drugs in Schedule II. • In an emergency, a prescription for Schedule II drugs may be telephoned to a pharmacy. If the pharmacy is willing to accept the telephone order, only enough drug to cover the emergency may be prescribed. The physician is then required to supply a written prescription to the pharmacy within 72 hours. The pharmacist is required to call the "Feds" if he doesn't receive the prescription within 72 hours. • "Emergency" means that the immediate administration of the drug is necessary to proper treatment, that no alternative treatment is available, and that it is not possible for the physician to provide a written prescription order for the drug at that time.

  25. Risk Management Strategies for Prescribers • Be Professional and Courteous • Keep Good Records • Provide Adequate and Informed Consent • Tell and allow Patients to call when necessary • Provide the Patient with a Realistic Assessment of Outcome, Benefit, and Adverse Reactions • Do not support False Expectations

  26. Let’s Write the Prescription!

  27. John Smith 4/12/10 25 Ankle sprain NKDA Motrin 600 mg tablet 50 tabs one po Three times daily PRN Pain 1 Catherine Marco, MD Catherine Marco, MD

  28. Questions?

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