P&T News: August 1998

Guidelines For Complete, Safe, And Accurate Discharge And Outpatient Prescription Writing

Pharmacy and Therapeutics Subcommittee
Peer Review Status: Internally Peer Reviewed

The Duplicate Prescription System at the UIHC is structured to produce an original and exact copy of the medication order. Under this system, the Department of Pharmaceutical Care is authorized to dispense the take-home supply of medication from the copy of the prescription and return the original prescription to the patient to obtain continuing supplies in the local community. The use of other, nonstandard prescription blanks within the UIHC is not authorized.

The "essential elements" of a prescription are depicted in the preceding figure of a UIHC prescription and described below:

A. Patient name, address, hospital number, birthdate and date prescription is written. This information may be transmitted to the prescription by using the patient's addressograph plate. The hospital number is essential to assure that the intended patient receives, and is billed for, the correct medication.

B. The name, strength, and quantity of the drug. Medications should be ordered by the generic name, not by the proprietary or trade names.

Hospital policy and the Joint Commission on Accreditation of Healthcare Organizations standards permit the use of drug name abbreviations in medication orders only if the abbreviation has been specifically approved by the hospital and it appears on a published list. "Coined" abbreviations such as HCTZ, AZT, T3, and ddC are not acceptable medical abbreviations, may be misinterpreted, and may cause drug errors. Medication orders that contain nonapproved drug name abbreviations are not valid. Pharmacists are authorized to withhold dispensing of medications ordered via nonapproved abbreviations. The approved drug name abbreviations are provided on pages 56-57 (gray-colored section) in the 1998 Formulary and Handbook; approved medical abbreviations are found beginning on page 165 of the pink- colored section.

A separate prescription blank must be used for each drug prescribed. Multiple prescriptions on a single blank are unsafe and greatly increase the potential for medication errors.

For Drug Enforcement Administration (DEA) narcotics and controlled substances, including anabolic steroids, the quantity should be written in words as well as numbers to prevent alteration of the prescription.

The quantity of drug to be dispensed should be indicated. Outpatient prescriptions should be written for no more than a 30-day supply with continuing supplies to be prescribed as refills. In order to minimize patient delays, the pharmacist is authorized to round the quantity dispensed to the nearest available prepackage quantity (usually a one-month supply) only for prescriptions with refills authorized.

Outpatient Prescription Medication Supply Limits

Supply quantities are generally limited to a 30-day supply except where health plan benefits allow a greater supply. Patients being discharged from the hospital may received an initial supply of medications. Refills are limited to the cases noted below. Refill prescriptions may be processed for: Patients receiving their on-going primary care from UIHC (i.e., generally local area residents as refills must be picked up monthly). Hospital staff and dependents at the same address. Prescriptions for medications which are not commercially available. Prescriptions for verified state paper (indigent) patients (as defined by UIHC policy). These patients are eligible for a maximum of 90-day supply with a single refill of specific maintenance medications

C. Directions to the patient. Clear and concise directions will assist your patient in the appropriate use of the medication. "Take as directed" should be avoided. Your patient may forget or confuse verbal directions or lose a separate note. The Department of Pharmaceutical Care will complete a patient medication calendar for tapered or intermittent dosage schedules. The "PRN" designation should include the purpose of the medication (e.g., PRN sleep, PRN pain).

D. Signature, printed name, physician code. In addition to signing the prescription, print your name legibly below your signature along with your UIHC 4-digit prescriber code, and indicate your practitioner status by circling the appropriate initials to the right of the signature line. This will facilitate communications with health care practitioners throughout the state who have a need to accurately identify the prescriber and it will also decrease the possibility of forgery. To prevent illegal drug diversion, supplies of prescription blanks may not be signed by the prescriber in advance of use. Prescriptions must only be signed by the prescriber at the time prescriptions are written for a specific patient. Physician assistants must also indicate the name of their supervising physician in the designated space.

E. DEA number. Your personal Drug Enforcement Administration (DEA) registration number (or the UIHC DEA registration number for eligible practitioners) with your personal 4-digit prescriber code must be included on all prescriptions for drugs classified as controlled substances. This step is a safety mechanism to prevent prescription forgery because each DEA number can be checked to verify its validity. When your DEA number is omitted, it is illegal for any pharmacy to fill the prescription. Pharmacy does not have a list of every physician's DEA number; therefore, this omission causes your patient to be inconvenienced until the deficiency is corrected.

Physician assistants and advanced registered nurse practitioners are authorized to prescribe controlled substances after obtaining a mid-level practitioner's registration from the DEA. However, physician assistants are not authorized to prescribe Schedule 11 substances listed as stimulants or depressants.

Applications forms for personal DEA registration at the UIHC and instructions for completion are available at the Pharmacy Office, Room CC-101 GH.

F. Drug allergies. The patient's medication allergies should be specified in this space on one of the prescriptions for each set of prescriptions. If there are no known allergies, please check the box next to "NKA. " The pharmacist will obtain or confirm allergy information with the patient as necessary at the time the prescription is presented to the Ambulatory Care Pharmacies.

G. Containers without safety closures. "Childproof" containers with safety closures are used for dispensing all prescription medications (with limited exceptions) in accordance with the Federal Poison Prevention Packaging Act of 1970. You may indicate the need for nonsafety closures for a patient for whom childproof containers may cause difficulty by checking the designated box.

H. Refill designation. Always circle "no refills" or specify the number of times and/or the last date the prescription may be refilled. "PRN" is not a valid refill designation.

Prescriptions may be refilled at the Department of Pharmaceutical Care ONLY if certain criteria are met (see page 6). Prescriptions for this eligible patient group (excluding controlled substances) may be refilled a maximum of 11 times or for 12 months - whichever is less. Prescriptions for DEA controlled substances in Schedules 111, IV, and V may be refilled a maximum of 5 times or for 6 months - whichever is less. Prescriptions for Schedule 11 controlled substances may not be refilled. State-paper eligible patients may receive a single refill of specific maintenance medications.

I. Indication for Use. The indication for use should be specified in this space for each prescription. This information permits the pharmacist to reinforce physician instructions with the patient and helps the patient understand the purpose for the medications. Federal regulations require the pharmacist to obtain information on the patient's disease state(s) so that appropriate utilization review and counseling can occur.

Discharge Prescriptions For Inpatients
Prescriptions for discharge medications should be in writing as all patients must be given the option of taking their prescriptions to their community pharmacy or having an initial supply filled by the UIHC Ambulatory Care Pharmacies. This should be determined 24 hours prior to discharge to allow time for the prescriptions to be filled at the UIHC Ambulatory Care Pharmacies and returned to the patient's bedside if the patient chooses this option. Failure to determine the need to have prescriptions filled at UIHC until the day of discharge can lead to delays in the patient's discharge and dissatisfaction with their stay. If prescriptions are filled by the UIHC Ambulatory Care Pharmacies, the patient will be billed by the hospital for the medications. The patient is responsible for filing any insurance claims for these take-home medications.

Telephoned Prescriptions
All UIHC physicians and dentists may telephone prescriptions for UIHC clinic patients to the UIHC Ambulatory Care Pharmacies during normal clinic operating hours.

The majority of patients being discharged from UIHC will not utilize the UIHC Ambulatory Care Pharmacies as their primary pharmacy and will require a written or verbal prescription for their local pharmacy.

Prescriptions for patients being discharged from the hospital must be in writing, as this ensures patients their legal right to choose where to have their prescriptions filled. Should the patient choose to have an initial supply of medications filled at UIHC, the inpatient pharmacist following the patient will review the patient's medication profile and counsel the patient about any prescribed home going medication therapy at bedside before discharge from the hospital.

Registered nurses, pharmacists, physician assistants and advanced registered nurse practitioners acting as an agent of a physician may also transmit prescription orders for clinic patients to the UIHC Ambulatory Care Pharmacies.

Unused Supplies Of Medication
Iowa law mandates that for the protection of the public health and safety, medications that have been dispensed to outpatients may not be accepted for return, exchanged, or resold. Therefore, the Department of Pharmaceutical Care may not accept medication returns or issue credit to patients who request return of unused supplies of medication. If the patient's reaction to a newly prescribed medication cannot be anticipated, it may be prudent to initially prescribe less than a 30-day supply. Continuing supplies may then be obtained as refills once it is determined that the patient can tolerate the medication.

Prescriptions For House Staff
The UIHC medical care program permits house staff physicians and dentists to write prescriptions to a maximum of a 30-day supply of medications as deemed appropriate based upon the package insert, if medically necessary, for themselves and members of their immediate family (defined as a spouse or child living with the house staff member) at no cost. Only medications on formulary may be prescribed. Certain high cost medications within specific therapeutic classes may be restricted, requiring a clinical faculty signature. Self-prescribing of these agents will result in the house staff member being billed the acquisition cost of the high cost medication. All prescriptions must reflect the name of the patient for whom the medication is being prescribed. Prescriptions will be monitored for appropriateness. Hospital policy requires that prescriptions for Schedule II narcotics written for immediate family and personal use must be signed by another member of the medical staff who possesses a personal DEA registration number (the hospital DEA number is not valid for this purpose).

To minimize waiting time for clinic and discharge patients, house staff are asked to plan ahead so that refills and new prescriptions for nonurgent medications are presented one day and picked up the following day. This will allow Pharmacy staff to fill house staff prescriptions at less busy times.

Storage Of Prescription Blanks
To reduce the incidence of theft of UIHC prescription blanks and to reduce illegal drug diversion, access to UIHC prescription blanks is limited. Prescription pads and single prescription blanks are stored only in secure centralized locations (e.g., medical conference rooms or medication preparation rooms) of the ambulatory care clinics and inpatient care units. Patients, visitors, and unauthorized hospital staff members should not have access to these locations. Prescription blanks must not be stored in patient examination rooms. Authorized prescribers may carry prescription blanks in their jacket/coat pockets.

In addition to controlled storage, prescription blanks are serialized, and dispersal of all prescription pads and storage destination is documented by Pharmacy staff. These procedures permit a trace of lost or stolen prescription blanks.

Medication Orders Written By Physician Assistants And Advanced Registered Nurse Practitioners
Physician assistants and advanced registered nurse practitioners may write medication and treatment orders only when acting pursuant to policies or protocols approved by the Clinical Service Head and reviewed and approved by the Professional Practice Subcommittee. Copies of established protocols shall be provided to the Department of Pharmaceutical Care by the Clinical Service Heads or the Professional Practice Subcommittee.

Physician assistants and advanced registered nurse practitioners shall not have the authority to limit substitution or standardization pursuant to Pharmacy and Therapeutics Subcommittee protocols and shall not be authorized to override protocol or restricted drug indications.

For further information on prescribing discharge and outpatient medications, please consult pages 59- 69 in the gold-colored section of the 1998 Formulary and Handbook or call the Department of Pharmaceutical Care.

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