The prescription

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					The prescription (Katzung, Chapt. 66) a. Rational prescribing: (1) Make a specific diagnosis (2) Consider the pathophysiology of the diagnosis selected (3) Select a specific therapeutic objective (4) Select a drug of choice (5) Determine the appropriate dosing regimen (6) Devise a plan for monitoring the drug's action and determine an end point for therapy (7) Plan a program of patient education b. For non-controlled substances (1) The prescription order can be written on any piece of paper as long as all of the legal elements are present or it may be telephoned to the pharmacy (the pharmacist reduces the information to a written prescription). The printed prescription form generally establishes the identity of the prescriber such as the name, license classification, address, and office telephone number. It may also include the prescriber's DEA number. (2) The prescription order should have the patient's name and address, the date written, and, if the patient is old or young, the patient's age and, for infants & children, the weight. Some advocate including allergies on the prescription. (3) The body of the prescription order contains the name of the medication (brand or generic), strength, quantity to be dispensed, the dose, complete directions for use, and the condition for which the drug is prescribed. e.g., Fluvastatin capsules 20 mg once daily

(a) The quantity of medication prescribed should reflect the anticipated length of therapy, the cost (a fee is paid each time an Rx is filled), the need for continued contact with the prescriber, the potential for abuse, and the potential for toxicity or overdose. When prescribing for a chronic disease the initial quantity should be small, with refills for larger quantities. Some insurance programs pay only for a one month supply at a time. (b) The directions for use must be drug-specific and patient-specific. Work in the field of pharmacogenomics indicates that there are inherited differences in the genetic makeup of enzyme systems and receptor sites. The drug name, dose, strength, route & frequency, purpose for which given, and duration of therapy should be written on each label. The fewer number of doses per day the better (for compliance). All prescription orders should be legible, unambiguous, dated, and signed clearly. Some common abbreviations used on prescriptions include: ac = before meals bid – 2 times a day g = gram h = hour hs = at bedtime IM = intramuscular IV = intravenous mcg = microgram mg = milligram mL = milliliter OD = right eye OS = left eye OU = both eyes pc = after meals PO by mouth

prn = as required stat = at once

qid = 4 times a day q-h = every – hours tid = 3 times a day tab = tablet

Additional suggestions (1) Prescribe drugs only for specifically diagnosed entities after nonpharmacological modalities have proven ineffective. (2) Stopping a drug is sometimes more beneficial than starting one. (3) Use the lowest possible dose and for as few days as possible (except for antibiotics). If there is a chance of misuse or abuse, spell out the amount prescribed, e.g., “dispense ten (10) tablets.” (4) Assess the therapeutic response regularly and adjust the drug accordingly (including stopping the drug if ineffectual or side effects are disabling). Monitor for adverse effects and be aware of possible drug interactions. Simplify the regimen if possible and keep the patient informed. (5) Use the correct dose for each drug and each diagnosis. Consider conditions that require dosage adjustment (e.g., neonate, elderly, impaired renal or hepatic function). Consider other medicinal substances (including OTC drugs or herbals) that the patient might be taking. (6) Some drugs should not be stopped abruptly (e.g., opioids, corticosteroids, anticonvulsants, antihypertensives, antidepressants). (7) Routine assessment is needed after discontinuation of some drugs (e.g., psychotherapeutics, antihypertensives). (8) Prescribing errors include omission of information, poor prescription writing, and inappropriate drug prescription. (Lehne p. 67) (9) Write or print clearly; double check legibility and accuracy (see October 1999 issue of Hospital Pharmacy for 11 pages of drug names that sound or look alike:) or use computer generated orders. Have another practitioner review the written prescription order. (10) Use standard shorthand (if at all). Avoid abbreviations for drug names. Avoid U for units (often interpreted as 0). (11) Be careful of decimal points (e.g., write 0.1, not .10; or 1, not 1.0). (A physician ordered .5 mg morphine (note: it should have been 0.5) for a 9 month old child. The clerk transcribed this as 5 mg. The nurse gave two 5 mg doses IV over two hours. The child died.) (12) Do not authorize generic substitution for drugs with possible generic inequivalence

Common problems in drug prescribing include Prescribing an excessively high dose. Prescribing a more toxic drug than necessary. Prescribing a drug that is unnecessary. Prescribing a drug that produces a drug-drug interaction. The prescription itself is flawed or illegible

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