9 7
Reflect Record keeping Review Negotiate a ‘contract’Consider the choice of product
Which strategy?
Consider the patient 7 6 5 4 3 2 1
Figure 10.1 The prescribing pyramid. Each step should be considered carefully before continuing to the next step (NPC, 1999).
1 Examine the holistic needs of the patient Is a prescription necessary? By first considering the holistic needs of the patient (such as their social and medical needs), early identification of non-drug therapy may become apparent, or perhaps the use of a complementary therapy in conjunction with mainstream medicinal therapy. Information such as the use of OTC medication or herbal or homoeopathic prepara- tions should also be taken into account. Some patients will not divulge this information freely to their prescriber, or may not consider it rele- vant. Any details of previous drug allergies should also be confirmed.
Some pharmacists find mnemonics useful to help them remember the critical questions to ask patients during a consultation. (One example is the WWHAM approach, devised by the NPC, to remind pharmacists of five key points to cover when dispensing an OTC medication.). Bear in mind, however, that such mnemonics cannot be relied on to examine all pertinent areas required in each consultation.
2 Consider the therapeutic target
When a prescriber meets with a patient, it is important to bear in mind that other treatment options should be considered before writing a prescription. Some questions a prescriber must consider include:
• Has a diagnosis been made?
• Does the patient need a prescription at all? • Are the patient’s expectations a factor? A prescription should only be given where there is a genuine need. It should also be remembered that patients may wish to receive a prescription for reasons other than to gain treatment for their condition (e.g. to legitimise the sick role, to gain attention, a friend has recommended it, or to get a prescription for a family member or friend).
3 Choosing a treatment and safety issues The following issues should be explored when considering which product to prescribe.
• How effective is the product? To ensure that the most appropriate prescription item is selected, the prescriber needs to be familiar with the full range of items in the British National Formulary (BNF), or the formulary to which they are restricted. To assess how effec- tive the product is, the available clinical evidence should be critically appraised. Websites such as the Department of Health’s Research Findings Electronic Register (ReFeR; www.info.doh.gov.uk/doh/refr_web.nsf/home) give up-to-date information on recently devel- oped, clinically trialled and newly released medicines. The National Library for Health (www.library.nhs.uk) provides information about treatment options for various illnesses. • How appropriate is the treatment? Some drugs are contraindicated (unsuitable for use) in certain patients. For example, aspirin (or medicines containing it) should not be taken by patients with current or previous history of stomach ulcers, as it can irritate the stomach lining causing bleeding. The patient’s medication history may also reveal potential drug interactions that may have serious consequences (e.g. warfarin and aspirin must not be taken together, because the combined anticoagulant effects of these two drugs may lead to an increased risk of bleeding).
In addition to choosing a product that is appro- priate for the patient, the dose, formulation and duration of treatment should be tailored to the individual. Generally, an initial prescription should provide treatment for no more than 1 month, in order to ensure an early follow-up consultation to check on the patient’s progress.
All drugs are associated with a certain risk of causing side-effects or adverse drug reac- tions (ADRs). ADRs account for 5% of all hospital admissions, and may be associated with a risk of significant morbidity and mortality (Pirmohamed et al., 2004). The West Midlands Centre for Adverse Drug Reactions Studies website (www.adr.org.uk) provides up- to-date information on the incidence of ADRs. ADRs are also discussed in more detail in Chapter 6. For any given therapeutic interven- tion, the potential benefits of the treatment must always be balanced against safety
concerns. The prescriber should be familiar with the common ADRs associated with the treatments they are prescribing.
4 Negotiate a ‘contract’ and achieve concordance with the patient
The prescriber and the patient should come to an understanding about the patient’s illness and discuss potential treatments that will help the patient to reduce the effect it has on his/her life. Further information on concordance can be found in Chapter 14. Effective communication is an essential part of good practice (see Chapter 8) and includes the need to make sure that the patient understands the information given. In the case of prescribing a medicine, the patient needs to understand:
• what the medicine is for • how to take the medicine
• at what dose and frequency to take it • how long it takes to work
• how long to take the medicine for
• the possible side-effects and what to do if they occur.
5 Review the patient on a regular basis
Reviewing the patient enables the prescriber to establish whether the treatment prescribed is effective, safe and acceptable. In an ideal world, patients should be reassessed at least every 6 months, with no more than six repeat pre- scriptions given without review, as outlined in a comprehensive document produced by the NPC (2004). Repeat prescribing without proper review may be wasteful and inefficient, and may even be potentially dangerous in some cases.
6 Record keeping
Record keeping must be both accurate and up- to-date – comprehensive notes on the patient’s
consultation, chosen drug regimen, test results and future appointments should be kept by the prescriber. In addition to this, the information recorded by the pharmacist (discussed in the following section) means a comprehensive record of the patient and their treatment is being maintained.
7 Reflection
This stage is often not considered until the patient returns for review with the prescriber. At this point the prescriber can decide whether the correct medicine regimen has been selected for the patient.
Interpretation of prescriptions
Once the prescription reaches you, the phar- macist, the next stage of the patient’s care begins. To dispense a prescription, a methodical approach should be adopted in order to allow the prescriber’s diagnosis and treatment choice to be conveyed accurately, with the correct medication, to the patient.
1 Check the patient’s details
Firstly, the patient’s details must be checked (see Figure 10.2). This allows the appropriate- ness of the treatment regimen for the particular patient to be assessed. Also, accurate records can be made of the product(s) dispensed, the product labelled for the patient, and the patient contacted, if necessary, after the medication has been dispensed and supplied to them. The full name of the patient is usually enough to indi- cate the sex of the patient, and therefore assess the appropriateness of a particular medication (e.g. finasteride should not be prescribed to women, except under certain circumstances when adequate contraceptive cover is in place, because it is highly toxic to developing male embryos).
The patient’s address is also required (see Figure 10.2). This allows the pharmacist to
distinguish between patients who may have the same name.
In the event that two patients have the same name and address, the date of birth (see Figure 10.3) should distinguish between them. This is also useful when calculation of appro- priate dosages for children is required. It is a legal requirement for the date of birth to appear on an NHS prescription for children under the age of 12 years, but not on a private prescription.
2 Check the legal requirements of the prescription
The legal requirements are described in detail in Chapter 9; a summary is provided in Figures 10.4 and 10.5.
3 Check the product details
By checking the name of the drug prescribed, the required pharmaceutical form, the strength and the total amount to be dispensed, the phar- macist can check that they have sufficient quantity of the medicine in stock in their dispensary. Many medications are now avail- able in ‘patient packs’ – a 28-day supply of medication in a box, complete with patient information leaflet – and it is not unusual for the prescriber to request ‘1 oP’, meaning ‘one original pack’ is to be supplied. The quantity of medication to be supplied should be checked to ensure that the prescribed quantity is appro- priate for the patient, as well as whether the medication is available in such a quantity. Some prescriptions are written to indicate that
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Chapter 10
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Understanding and interpreting prescriptions
Patient’s name Patient’s address
Figure 10.2 Check the patient’s name (title, forename and surname) and address. The address is useful to distinguish between patients with the same name.
Age Date of birth
Figure 10.3 Check the patient’s age and date of birth. The latter is useful to distinguish between patients with the same name and address. This information is also important to identify when the prescription is for a child.