P&T News: August 1997

Guidelines for Complete, Safe, and Accurate Discharge and Outpatient Prescription Writing

Pharmacy and Therapeutics Subcommittee
Peer Review Status: Internally Peer Reviewed

Duplicate Prescription System
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

(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, MSO4, 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.

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
The United States Supreme Court has ruled that medications purchased by hospitals (at special institutional prices) must be for inpatient use or for dispensing a limited take home supply. The following rules must apply:

1. A maximum 30 day supply is authorized on prescription orders.
2. Refill requests may not be processed.
3. Exemptions from the above rules:

• Prescriptions for medications not commercially available.
• Prescriptions for UIHC staff and dependents at the same address.
• Prescriptions for state paper eligible patients (as defined by UIHC policy). These patients are eligible for a maximum 90 day supply with a single refill of specific maintenance medications. (See guidelines on pages 9 to 10.)

(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, prescriber code. In addition to signing the prescription, print your name legibly below your signature along with your UIHC "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 prescriber'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 II 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.

(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 Pharmacy.

(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 for hospital staff and dependents at the same address or for patients whose medications are not commercially available. Prescriptions for these eligible patients groups (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 III, IV, and V may be refilled a maximum of five times or for six months whichever is less. Prescriptions for Schedule II controlled substances may not be refilled.

(I) Indication for Use. The indication for use should be specified in this space for each prescription. This information permits the pharmacist to reinforce prescriber instructions with the patient and helps the patient understand what the medications are for. 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
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 Pharmacy. This should be determined 24 hours prior to discharge to allow time for the prescriptions to be filled at the UIHC Ambulatory Care Pharmacy 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 Pharmacy, 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.

Prescriptions for Clinic Patients
Prescriptions forwarded to the Department of Pharmaceutical Care for patients being seen in the clinics should note when the patient will call for the prescription and in what clinic the patient was seen. This allows timely medication preparation and classification of prescription orders if necessary.

Telephoned Prescriptions
Prescription orders for "take home medications" are not permitted to be telephoned to the Department of Pharmaceutical Care with the following exceptions:

1. Orders from UI Care or UI Unity Choice primary care physicians;
2. Orders from clinical faculty and fellow associate physicians and dentists under the following conditions:

• The clinical faculty or fellow associate physician or dentist must personally place the call; prescription orders called in by agents of the physician or dentist (e.g., nurse, clerk, student, or resident) can not be accepted.
• Clinical faculty and fellow associate physicians and dentists are encouraged to utilize written prescriptions for themselves or their dependents in order to minimize the potential for affecting UIHC clinic patient service.
• Prescription orders for patients who are not UIHC staff or state pay patients cannot include refills as the UIHC Ambulatory Care Pharmacy may not provide continuing supplies (i.e., refills) for these patients.

3. Emergency situations: In emergency situations, the prescription order must be countersigned by the prescribing physician or dentist within 72 hours. This policy is intended to reduce prescription forgeries and to provide the mechanism for a double check on written prescription orders as a safety measure. Physician assistants and advanced registered nurse practitioners may not dictate oral orders for any medications which are to be prepared or dispensed within the UIHC.

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 charges 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 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.

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