"A Guide to Prescribing for 5th Year Medical Students"
Controlled Drugs: Specify whether tablets, capsules or liquids are required Specify slow (modified) release or fast-acting Some drugs should be prescribed as brand names Write doses in figures and words, and if the dose is to be changed, cross out and date the old dose, and start the new dose on a new line. Start patients on 10mg every four hours with 10mg PRN A Guide to Prescribing for 5th available hourly After 24 hours divide the total morphine given by 6 to give new Year Medical Students 4 hourly dose, with the same dose PRN Diamorphine dose – divide oral morphine dose by three Outpatient prescription – must be hand-written Fentanyl patches – write patch strength & duration Avoid using decimal points in doses Error Reporting: If you make or spot a mistake, even if the patient wasn’t affected, It would be impossible to write a guide detailing how to report it. Most errors are currently reported by nursing and pharmacy staff. By reporting errors, action can be taken so that prescribe all types of drugs for every scenario – that’s what other staff become aware of problems, and prevent them from the BNF is for. Instead, this is a collection of useful hints from recurring. Also record any adverse drug reactions – yellow card nursing and pharmacy staff on how to avoid the most common scheme. errors made by PRHOs, and how to make your life (and everyone else’s lives) a bit easier. And hopefully help you Help: pass the drug chart OSCE station! The BNF remains the first If you are uncertain about something, contact the ward or an on-call place to look for drug doses, interactions and pharmacist, or a senior doctor. Senior nurses are also a mine of contraindications, including the appendices at the back. As information. Never write a prescription if you are unsure – if drug charts differ between trusts, I haven’t included any something goes badly wrong, the blame will fall to whoever signed specific drug charts in this guide. the prescription. Pharmacy phone/bleep number…………………………….. General Hints for Drug Charts: Therapeutic Drug Monitoring: Check the patient’s name is correct and is on every page aminophylline, theophylline, digoxin, gentamicin, lithium, phenytoin, Check that any allergies are documented in the notes and on every vancomycin all require blood tests to check their levels. Hospitals page of the drug chart (and document reaction) have protocols of when to check blood levels and how often. Weigh patient if possible and record weight On admission, record drug history carefully – including doses Warfarin: Sign and date everything – including when stopping a drug or Follow hospital guidelines and don’t just guess changing a dose. Write in bleep number too New patients need counselling – lots still drink alcohol Write legibly in pen, preferably in capital letters – nurses will refuse to Timing of blood tests: try to get them done early enough so the give drugs if they can’t read it properly, and it must be fax-proof medical team can prescribe (not the on call team) Write out nanograms and micrograms in full to avoid confusion Use LMWH with Warfarin for at least 5 days, until there have been two Route of administration is important, especially if patient is NBM consecutive therapeutic INRs When changing a dose, ideally cross through the old drug and rewrite Write on main drug chart that patient has separate Warfarin chart it on a new line. One dose change on the same line is acceptable – so Arrange an INR appt around 2 days after discharge long as date of change is recorded Ensure that patient knows what dose to take – not just with “as Rewrite charts when they’re about to run out – nursing staff cannot directed” written on the box give drugs if there’s nowhere to sign for them Sort out who will monitor INR (GP/clinic), and make sure patients Write charts up to cover weekends – shouldn’t be the job of the on-call knows to chase their INR results doctors Inform nursing staff of any changes to medication Antibiotics & Steroids: Avoid overdosing patients by putting drugs on regular and PRN Remember to write in the course length and stop date prescriptions – especially paracetamol Check hospital antibiotic policy – eg UBHT provide stickers Remember to write patients up for Warfarin and insulin every day Steroids – write down options for weaning off steroids Prescribe by generic name except lithium, theophyllines, slow release Ca channel blockers and some controlled drugs Unusual medications: Think about the timing of drugs around food and sleep – eg don’t give Some drugs cannot be prescribed by GP – ensure patient is covered frusemide at night, or steroids after lunch. until next Outpatient appointment Doset boxes – arrange for GP to take over after 1 week’s supply st Holistic prescribing – write up something PRN for common side effects of drugs. Most patients should have paracetamol, a laxative and an Write down drug regimes and indications for uncommon drugs – helps antiemetic written up PRN pharmacy know how much to supply Remember to write maximum frequency for PRN drugs NEVER GIVE VINCRISTINE INTRATHECALLY When rewriting charts, write on the original drug start dates Review medications on discharge – discontinue IV drugs Document drug changes and reasons in GP discharge letter