Prescription Writing 101

1. Prescription Writing 101 Gail Feinberg, DO, FACOFP October, 2009

2. Objectives Understand what “makes” a prescription Intro to Latin abbreviations Intro to DEA Practice writing prescriptions

3. The parts of a prescription

4. What is a 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" evidence in a court of law. • (side note…A prima-facie case is a lawsuit that alleges facts adequate to prove the underlying conduct supporting the cause of action and thereby prevail.)

5. Definition Literally, "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).

6. Definition • The 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".

7. Parts of the Prescription Patient Information Superscription Inscription Subscription Signa Date Signature lines, signature, degree, brand name indication Prescriber information DEA# if required Refills Warnings/label

8. Patient Information Name Address Age Weight (optional, but useful - esp in peds) Time (used only with inpatient medication orders)

9. Superscription RX Traditional symbol for prescription Use it to line up the other parts of the Rx

10. 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!)

11. 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

12. Signa, Signatura or Transcription • Sig—write, or let it be labeled (Latin terms: signa or signetur) • 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… • Duration of dosing • for 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 directed” • Special instructions (shake well, refrigerate etc.) • Warnings

13. Refills and Date Prescribed • Indicate either no refills or the number of refills you want (don’t leave it blank) • Determines maximum duration of therapy. • Date the prescription • All prescriptions expire after one year • Schedule II drugs can only be dispensed within 7 days of date on RX • CV-CIII can be refilled for 5 time in 6 mo. maximum. • Automatic Stop Orders (inpatient orders) • Antibiotics-7 days • Controlled Substances-3 days

14. Signature of Prescriber This makes the prescription a legal document Include your degree You must write “brand necessary,” “brand medically necessary,” or “DAW” (Dispense as Written) to get non-generics.

15. DEA

16. DEA (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.

17. DEA Number detail…The first letter in the code is the type of practice • A – Deprecated • B –Hospital/Clinic • C – Practitioner • D – Teaching Institution • E – Manufacturer • F – Distributor • G – Researcher • H – Analytical Lab • J – Importer • K – Exporter • L – Reverse Distributor • P- Narcotic Treatment Program • R – Narcotic Treatment Program • S – Narcotic Treatment Program • T- Narcotic Treatment Program • U – Narcotic Treatment Program • X – Suboxone/Subutex Prescribing Program

18. DEA Number detail… • The 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 digits • Addition of the second fourth and sixth digits times two • Add the sums of the two numbers • The sum is the last digit

19. Latin abbreviations

20. Latin Used in Prescription Writing

21. Latin Used in Prescription Writing file:///C:/Documents%20and%20Settings/Gail%20Feinberg/Desktop/List_of_abbreviations_used_in_medical_prescriptions.htm file:///C:/Documents%20and%20Settings/Gail%20Feinberg/Desktop/List_of_medical_abbreviations%20_Do-not-use_list.htm

22. Preventing Medical Errors

23. Avoiding Medical Errors • Prescribing incorrectly • Can be due to slips, lapses or lack of knowledge (mistakes) (Always check dosage calculations!!!!!!) • Using ambiguous symbols • Poor handwriting

24. Avoiding Ambiguity • Careful 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 500 mg. • “mL" is used instead of “cc" or "cm³" 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.

25. Avoiding Ambiguity Where 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" instructions—instead, 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."

26. Avoiding Ambiguity • Writing out numbers as words and numerals ("dispense #30 (thirty)“) • The use of apothecary units and symbols of measure is discouraged • pint (O), ounce (℥), drams (ℨ), 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).

27. Prescription Security • To prevent copying of prescription/pad • Anti-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.

28. Prescription Security • To prevent modification of prescription • Toner 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.

29. Prescription Security • Security measures to prevent counterfeiting of prescription forms • Unique 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.

31. Practice Problems

32. Practice #1 Write 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 days

33. Prescription should say… Amoxil 250/5ml Disp: 150mL Sig: 5mL tid until gone

34. Denise Watermark Oct. 6, 2009 Amoxil 250/5ml Disp: 150mL Sig: 5mL tid until gone (also acceptable is 5mL tid x 10 days) Gail Feinberg, DO, FACOFP none

35. Practice #2 Jane 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 off…write both for her.

36. 30 day will look like… Jane Doe Digoxin 1.25 mg Disp: #30 Sig: One p.o. daily (here can also add for CHF or whatever appropriate) No refill

37. Jane Doe 10/7/09 Digoxin 1.25mg Disp # 30 Sig: One (1) po daily (can also add for CHF)

38. 90 day will look like Jane Doe Digoxin 1.25 mg Disp # 90 Sig: One p.o. daily No refill

39. Jane Doe 10/7/09 Digoxin 1.25mg Disp # 90 Sig: One (1) po daily (can also add for CHF)

40. Practice #3 Tom 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.

41. Prescription should look like.. • Tom Smith • Flexeril 10mg • # 21 (twenty one) • ip.o. up to tidprn muscle spasm • (note the i…represents one ii=2, iii=3, iiii or iv = 4 etc.) • Can also write one (1) po up to …

42. Tom Smith 10/7/2009 Flexeril 10mg DAW #21 (twenty one) 1 po up to tidprn muscle spasm Caution: May cause drowsiness none