LECTURE 05 Prescription Handling .pptx

PRESCRIPTION HANDLING
(Parts of a Prescription)
Lecture # 05
PHARMACY PRACTICE-IIA (DISPENSING PHARMACY)
PHM-6503

REFERENCE BOOK
• Jannie Watson, Rees J, Smith I.
Pharmaceutical Practice. 5th Ed. Churchill
Livingstone; 2014.
Chapter # 20 (Pg. 187-193)
RAHAT FATIMA (LECTURER, DOP, IIUI) 2

THE PRESCRIBING PROCESS &
EVIDENCE-BASED MEDICINE

INTRODUCTION
The prescribing of medicines is the most common medical
intervention in patient care and drug costs are a major component of
NHS expenditure. Ensuring optimum benefits for patients and value
for money for taxpayers and other individuals and organizations
paying for health care are priorities and a model of ‘good prescribing’
has been proposed that has four aims.
These aims are to:
• Maximize effectiveness
• Minimize risks
• Minimize costs
• Respect patient choice

INTRODUCTION
• Maximizing effectiveness is about selecting a drug therapy that will
achieve its therapeutic objective in a suitable timescale.
• Minimizing risks is recognizing that all drug treatments carry an
element of risk of causing harm to the patient and that selection of
the drug should be about managing these benefits and risks.
• The cost of therapy should also be taken into account by the
prescriber although such consideration should go beyond a simple
review of the drug costs but also consider any costs of monitoring
treatment such as blood tests, length of treatment and any additional
items that could be required such as prescribing an additional drug
to protect the gastrointestinal tract from adverse effects caused by
the first.

INTRODUCTION
• Establishing the views of the patient is a vital part of the process of
assessing the relative importance of the first three aims in this
model. Patients may differ in their views regarding managing the
symptoms of a condition, living with the consequences of a
condition, exposing themselves to risks of harmful effects and the
amount of money they would be willing or able to pay for treatment.
• In addition, patients may wish product selection to take their lifestyle
into account such that the frequency and route of administration of
the selected product fits in with their daily routine.
• It is accepted that ‘good prescribing’ involves trade-offs between
these four aims and that this often involves delicate balancing
between each of the aims.

Parts of a Medical Prescription

Patient's Address:
Diagnosed With:
Blood Pressure: Pulse Rate: Weight:
Allergies: Disabilities if any:
Patient´s Name:
Date of Birth: Age: Sex: Occupation:
Health Insurance Number: Health Care Provider:
Health Card Number: Patient ID Number:
DRUGS
Unit
(Tablet/Syrup)
Dosage (Per
day)
1
2
3
4
5
6
Diet to Follow:
Brief History of Patient:
Medical Prescription
Doctor´s Signature
Date:

THE PRESCRIBING PROCESS

The prescribing process will be considered
under five headings although there is some
overlap between these and their sequence
may not be the same in all cases. The first
is concerned with all the things that must be
in place before a prescriber can start to
prescribe; the second with collecting
information; the third with analyzing the
information and making the prescribing
decision and the fourth with making
appropriate records and plans for monitoring
the patients progress and the last with
auditing and evaluating prescribing practice.

PRE-REQUISITES
• Prescribing can only be carried out by healthcare professionals that
have the appropriate prescribing qualifications and these will vary
depending on the type of prescribing to be carried out. To prescribe
prescription only medicines on the NHS or privately the prescriber, if
not a medical prescriber, must have successfully completed the
training to allow them to act as a supplementary or an independent
prescriber.
• The training course consists of a taught element (around 26 days)
and learning in practice (around 12 days), which includes prescribing
under the supervision of a medical prescriber. To participate in a
minor ailment scheme and prescribe pharmacy only medicines at
NHS expense the pharmacist will likely have had to complete
appropriate accreditation set by the local primary care organization.

PREREQUISITES
• Patients that are to receive their prescriptions from a supplementary
prescriber must give informed consent. Patients do not need to sign
this informed consent but is good practice to make a note in the
patient’s medical notes when informed consent was given. The exact
nature of informed consent is difficult to define and it is likely that the
input from the healthcare professional will vary between patients
when obtaining consent.
• Observation of disputes between patients and physicians regarding
whether informed consent was given show that simply handing the
patient a leaflet does not discharge the physician from their
obligation to obtain informed consent.

PREREQUISITES
• In any legal dispute it is up to the courts to decide which party they
believe but the disputes that found in favor of the physician tended to
be those where the physician was able to demonstrate that they had
given the information to the patient because they had documented
the advice they gave in the patient’s medical records. Prior to the
patient consultation, the prescriber should ensure that they are
suitably prepared. Part of this preparation includes ensuring they
have sufficient indemnity insurance that covers their prescribing and
that their job description clearly shows that prescribing is part of their
role.
• Another part of the preparation is acquiring the appropriate
knowledge and skills.

Checklist for knowledge and skills required by pharmacist prescribers
Legal restrictions
effecting
which medicines can be
prescribed
Independent pharmacist prescribers can prescribe any
licensed or unlicensed medicine except diamorphine,
dipipanone or cocaine for treating addiction but may
prescribe those drugs when treating organic disease or
injury.
Supplementary prescribers can prescribe any licensed or
unlicensed medicine including controlled drugs provided it
has been specified in the clinical management plan.
Professional restrictions
effecting which
medicines
can be prescribed
It is vital that each prescriber only prescribes within their
own area of competence. Knowing one’s own limitations is a
key skill for a prescriber. In addition, they must also have an
appropriate level of experience dealing with the condition
and it might be appropriate to refer a patient presenting
with a condition rarely experienced to another prescriber for
assessment and any prescribing

Administrative
arrangements
regarding payments for
the
service
The administrative arrangements regarding the prescribing
process must be fully understood. In the case of minor
ailments schemes these arrangements could include a
description of records that should be kept and how payment
for the service is to be made. For NHS prescribing the
prescriber should be aware of the categories of patient that
are exempt from NHS charges and what payments should be
made by those that are not exempt.
Patient confidentiality Pharmacist prescribers must maintain patient confidentiality
and take steps to ensure that no unauthorized personnel can
gain access to patient medication records by securely storing
the data either via lock and key or via appropriate electronic
security measures such as passwords for data stored
electronically.

Ethics Prescribers should be aware of the good practice guidance
from the DH and the GPhC before they start to prescribe.
The DH guidance addresses prescribers not prescribing for
themselves, not normally prescribing for members of their
family and also covers accepting gifts and hospitality for
suppliers. Pharmacist prescribers must also comply with the
GPhC Standards of conduct, ethics and performance.
Security Prescribers must be aware of security issues surrounding
prescribing and take steps to minimize the risks. Blank
prescription forms could be used by drug misusers to try and
obtain supplies of prescription medicines for abuse or to sell
to others. Care must be taken to ensure that the forms are
securely stored. Personal security must also be considered if
the prescriber is visiting patients in their own homes or
other locations in the community.

Therapeutic
management
of conditions
A pharmacist’s knowledge and skills required for the
management of a therapeutic area must be up to date and
based upon the best evidence available at the time. The
knowledge should extend to non-drug approaches to
treatment as sometimes these could be the most
appropriate
Other members of the
healthcare team
Prescribers should be aware of other professionals they
could refer patients to, e.g. general practitioner, the accident
and emergency department in the hospital, dentists, the
community nursing service (district nurses and health
visitors) social services and self help groups

PRESCRIBING DECISION-MAKING
• Upon analysis and interpretation of the patient’s signs, symptoms and laboratory
test results, the prescriber must consider the treatment options including the
option of offering no treatment to the patient. The consideration of therapy
options must include concurrent diseases and concurrent medication, the
patient’s lifestyle (would the treatment regime fit in with the patient’s schedule or
would side-effects of drugs affect their ability to perform their usual activities, e.g.
driving).
• A key component of this phase is involving the patient in the decision-making in
order to achieve concordance.
• The prescriber must communicate the benefits and risks of the different
treatment options to the patient or their carer The principles of concordance
dictate that patients should fully participate in the decision making process and a
consultation style where patients are treated as equals and have the opportunity
to ask questions and to raise any concerns or worries they might have helps to
achieve this. RAHAT FATIMA (LECTURER, DOP, IIUI) 18

• Following selection of the drug and formulation, the dosage regime
must be determined. The dosage guidance in the summary of
product characteristics, BNF or local and national clinical guidelines
should be used to work out the dosage to be prescribed.
• In general it is recommended that dosage be started at the lower end
of the dosing schedule and that the dose should be gradually
increased until the required therapeutic benefits are seen and side
effects are minimized. However, there are many exceptions to this
such as prescribing a loading dose for certain antibiotics or
prescribing drugs where the therapeutic benefits are not obvious
such as drugs used in prophylaxis.

• The prescriber must also indicate the quantity to be supplied on the
prescription. The quantity to be supplied will depend upon whether
the treatment is likely to be acute or chronic. If the treatment is acute
then the quantity is likely to be enough for the recommended course
of treatment.
• When determining the quantity to be supplied for a chronic condition
the prescriber should bear in mind the frequency that they would
wish to review the patient, whether the patient has to pay for the
item, the patient’s ability to pay the prescription levy and whether
there are any dangers from accidental or deliberate overdose.

• In general, smaller quantities offer the opportunity to review patient’s
therapy more frequently and reduce waste if patients are unable to
take their medicine through the occurrence of troublesome side
effects or adverse drug reactions. However, smaller quantities can
cause greater patient inconvenience as patients will to visit
healthcare professional more frequently and greater expense if they
have to pay for their medication, as well as increasing the
prescriber’s workload.

RECORDING & MONITORING
• It is important to realize that the responsibilities of the prescriber do
not end with signing the prescription.
• The prescriber must make appropriate records of the medicine(s)
prescribed and any advice given to the patient in the patient’s
medical notes. For paper held records the prescriber will obviously
have to write the name of the prescribed item, the formulation, the
strength, dosage instructions in the notes. In the case of electronic
prescribing the details of what was prescribed, the date of
prescribing and the directions will be stored automatically in the
patient’s records. However there may be a need to record additional
information such as when the patient should next be reviewed and
the monitoring that is recommended.

AUDITING PRESCRIBING PRACTICE
• Prescribing audits involve reviewing prescribing activity against a set
of explicit criteria such as a set of local or national clinical guidelines.
For example, this could involve reviewing the prescribing for all
patients registered with a practice that have a diagnosis of angina
and comparing this with the guidance published by NICE. The audit
should specify the standard of compliance with the guideline that is
expected (e.g. 90% or 100%). If the audit reveals that expected
standard of compliance has not been met then there should be a
review of practice to identify why the standard has not been met.
• Prescribers should reflect upon the findings of the review and agree
what action is required. The audit should then be repeated to
determine whether the action has had an impact on the compliance
with the standard. An audit cycle involves repeating the audit, review
and action RAHAT FATIMA (LECTURER, DOP, IIUI) 23

EVIDENCE-BASED MEDICINE

EBM
• Evidence-based medicine (EBM) has been described as ‘a
means of closing the gap between research and everyday
practice and ensuring that clinical decisions are based upon the
best available scientific evidence’. It allows healthcare
professionals to compare the evidence for different treatment
options. This comparison may sound easy but unfortunately the
available evidence is frequently of variable quality, which makes
comparisons difficult.
• The process of EBM involves four stages.

STAGES OF EBM
1. The first involves identifying the question to be answered such as:
Does treatment with drug X prevent more cardiovascular events
than drug Y?
2. The second stage involves searching the literature to find studies
that have compared drug X with drug Y.
3. The third stage is a critical appraisal of the studies that have been
identified which involves making judgements about the quality of the
studies, comparing the evidence supporting drug X with the
evidence supporting drug Y and determining whether the balance of
evidence favors one drug over the other.
4. The final stage is about applying the evidence to clinical practice,
which could involve recommending one drug be prescribed by
clinicians rather than the other.

Prescription Dispensing
(Good Dispensing Practices)

Receiving the Prescription
• The patient walks into the pharmacy and presents the prescription.
At this stage, communication and interaction with the pharmacy staff
take place. In the modern age of electronic documents, e-prescribing
is already being practiced in some countries and is expected to
develop even further. In electronic prescribing, the prescription is
transferred electronically and the pharmacist receives an electronic
document.
• Once the patient presents at the pharmacy and provides the required
details for retrieval of the electronic prescription, the process of
communication and interaction with the patient commences.

Reading & Checking of Prescription
Prescription is reviewed to see which medicines are required and to
note patient details. Pharmacy staff should check:
• Patient’s name and address
• Age of patient if under 12 years
• Name, dose and quantity of medicine
• Date
• Prescriber’s name and address
• Signature of prescriber
• Legality and authenticity of document.

Collection of Medicine
This step may be carried out either manually, where the pharmacy or pharmacy
assistant picks up the required product from the pharmacy storage section, or
mechanically, where the pharmacist requests the product through a machine
interface and the product is selected from the magazine and delivered at the
dispensing bench.
During this step, pharmacist intervention to decrease occurrence of dispensing
errors includes:
• Care in selecting appropriate medicine; there are some medicines that have very
similar names (e.g. amlodipine and amiloride, Lescol and Losec)
• Care in selecting the appropriate strength; there are medicines that are available
in different strengths (e.g. amoxicillin 250 and 500 mg capsules, atenolol 25, 50
and 100 mg tablets)
• Care in selecting the appropriate dosage form; there are medicines that are
available in different dosage forms (e.g. diclofenac gel, tablets, modified-release
tablets, suppositories).
RAHAT FATIMA (LECTURER, DOP, IIUI)
31

LABEL PRODUCTION
The label should be clear and
legible to ensure that the
patient takes the medicine as
prescribed. The information
presented has to be
understood by the patient.
Details to be included on
label:
• Patient’s name
• Date of dispensing
• Name of pharmacy
• Name of medicine
• Strength
• Dosage form
• Quantity dispensed
• Dose with clear instructions
• Cautionary labels.
RAHAT FATIMA (LECTURER, DOP, IIUI)
32

CONTAINER SELECTION
• If, during the dispensing process, there is a requirement to repack
the medicines, the appropriate container should be chosen for the
medication. This includes taking into consideration stability of the
product and interaction of the product with the material used for the
container. Usually repacking takes place in a controlled area under a
quality assurance system and pre-packs are produced to be
available for the pharmacist during the dispensing.
• In the UK, original pack dispensing is required, whereby the
pharmacist can dispense branded or generic products as packaged
in the original form as produced by the manufacturer.

RECHECKING
• Recheck that the prescription and the medicine prepared are
consistent and that the right medicine in the right dosage form
and strength has been identified, that the right label is attached
and that the right patient instructions are provided.

HANDING OVER MEDICINE
• The pharmacist hands over the medicine and explains to
the patient when and how to take the medication.
PATIENT COUNSELING
ACTIVE PASSIVE

COMMON ABBREVIATIONS USED IN
PRESCRIPTIONS

PRACTICE SUMMARY
• The pharmacist should ensure that the dispensing process
implemented in the pharmacy implies the correct attitude and
transfer of knowledge from reading the prescription to the handing
over of the medicine to the patient.
• The dispensing process includes communication and interaction
between the patient and the pharmacist. The way that this interaction
takes place may influence the efficacy of the dispensing process.
• The dispensing process employed could be outlined in good
dispensing procedures to ensure standardization of the dispensing
process within a pharmacy.

PRACTICE SUMMARY
• Pharmacist intervention should ensure that the process eliminates
dispensing errors. Factors that decrease dispensing errors include:
dispensary layout and workflow, systems of drug storage, lighting,
limitation of noise and use of electronic equipment (e.g. scanners).
• Pharmacist intervention should ensure that the patient understands
the use of the medicine, its correct application and information about
any side-effects expected and action that might need to be taken in
the case of missed doses.
• When the customer is not the patient but a proxy, emphasis should
be placed on the need for correct onward transmission of the
information to the patient or carer.

CLASS ACTIVITIES

ACTIVITY # 01
• For each of the following abbreviations, which may be used on
prescriptions, give a brief explanation and an example of a
product for which this abbreviation is used, stating generic
name and dosage form(s): p.c., p.r.n.
p.c. – after food, ibuprofen (tablets, suspension).
p.r.n. – when required, paracetamol (tablets, soluble tablets,
suspension, suppositories).

ACTIVITY # 02
For each of the following cautionary and advisory labels, give one
example of a drug where the label should be used:
(a) May cause drowsiness
(b) Do not take milk, indigestion remedies and medicines containing
iron or zinc at the same time of day as this medicine
(c) Take at regular intervals. Complete the prescribed course unless
otherwise directed.
(a) May cause drowsiness – hydroxyzine.
(b) Do not take milk, indigestion remedies and medicines containing iron or
zinc at the same time of day as this medicine – ciprofloxacin.
(c) Take at regular intervals. Complete the prescribed course unless
otherwise directed –co-amoxiclav.

ACTIVITY # 03
• Give two examples of products that should be taken after food.
Give reasons for your choice.
(a)Diclofenac potassium tablets – should be taken after food to
minimize gastrointestinal irritation.
(b)Itraconazole capsules – should be taken after food to ensure
optimal absorption.

LECTURE 05 Prescription Handling .pptx

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LECTURE 05 Prescription Handling .pptx