Catherine A.

Marco, MD, FACEP

Goals & Objectives
Describe the proper physician-patient relationship
Describe clinical decision making regarding
medication prescriptions
Delineate the basic components of a written
prescription
The Physician-Patient
Relationship
Patient identification
Establish diagnosis
Treatment plan, options, counseling
Follow-up care
Online or telephone evaluations are not adequate
A pharmacy may not fill a controlled substance
prescription in the absence of a proper physician-patient
relationship
Prescription

A prescription order is written for diagnosis,

prevention or treatment of a specific patient's disease
Is written by a licensed practitioner
Is written as part of a proper physician-patient
relationship
Is a legal document, "prima facie" evidence in a court
of law.
Over-The-Counter -OTC

Patient can use drug safely by reading the labeling

instructions.
Examples
analgesics like aspirin and ibuprofen
topical antibiotics
Cough and cold remedies
Some vitamins
Rx Only Drugs

Can only be dispensed on a prescription order

Synonyms: Legend (or dangerous)
Physician training required to use safely
Examples
Most systemic antibiotics
Cardiovascular drugs
Most drugs that have dependence liability
Controlled Substances
Drugs with abuse potential
Classification CI, CII, CIII, CIV, CV
Schedule III,IV, V are obtained on a regular prescription
Must include date
Must include prescriber DEA#
Schedule II drugs require an official Rx form
(formerly used a triplicate Rx)
Schedule I, some drugs (chemicals) may not be available
by any legal means
Heroin
LSD
Schedule I
The drug or other substance has a high potential for
abuse.
The drug or other substance has no currently accepted
medical use in treatment in the United States.
There is a lack of accepted safety for use of the drug or
other substance under medical supervision.
Some Schedule I substances are heroin, LSD,
marijuana, and methaqualone.
Schedule II
The drug or other substance has a high potential for
abuse.
The drug or other substance has a currently accepted
medical use in treatment in the United States or a
currently accepted medical use with severe restrictions.
Abuse of the drug or other substance may lead to
severe psychological or physical dependence.
Schedule II substances include morphine, PCP,
cocaine, methadone, and methamphetamine.
Schedule III
The drug or other substance has a potential for abuse
less than the drugs or other substances in Schedules I
and II.
The drug or other substance has a currently accepted
medical use in treatment in the United States.
Abuse of the drug or other substance may lead to
moderate or low physical dependence or high
psychological dependence.
Anabolic steroids, codeine and hydrocodone with
aspirin or Tylenol, and some barbiturates are Schedule
III substances.
 Schedule IV
The drug or other substance has a low potential for abuse
relative to the drugs or other substances in Schedule III.
The drug or other substance has a currently accepted
medical use in treatment in the United States.
Abuse of the drug or other substance may lead to limited
physical dependence or psychological dependence relative
to the drugs or other substances in Schedule III.
Included in Schedule IV are Darvon, Talwin, Equanil,
Valium and Xanax.
 Schedule V
The drug or other substance has a low potential for abuse
relative to the drugs or other substances in Schedule IV.
The drug or other substance has a currently accepted
medical use in treatment in the United States.
Abuse of the drug or other substance may lead to limited
physical dependence or psychological dependence relative
to the drugs or other substances in Schedule IV.
Over-the-counter cough medicines with codeine are
classified in Schedule V.
Parts of the Prescription
Rx (an abbreviation for "recipe," the Latin for "take thou.)
Superscription (Patient Information)
Inscription
Subscription
Signa
Date
Signature lines, signature, degree, brand name indication
Prescriber information
DEA# if required
Refills
Warnings
Patient Information

Name
Address
Age (Required on triplicate or official)
(30y/o)
Weight (optional, but useful)
Time-(inpatient medication orders)
Inscription
What is the pharmacist to take off the shelf?
Drug Name
Dose = Quantity of drug per dose form
Dose Form = The physical entity needed, i.e.
tablet, suspension, capsule
Simple vs Compound Prescriptions
Manufactured vs compounded prescriptions
Clarity of number forms 0.2, 20| not 2.0
(Zeros lead but do not follow!)
Subscription

What is the pharmacist to do with the

ingredients?
Quantity to be dispensed (determines amount in
bottle) Dispense # 24
For controlled substances write in numbers and
letters (like a bank check)
#24(twenty four)
Any special compounding instructions
Signa, Signatura or Transcription
Instructions for the patient
Route of administration: Oral, nasally, rectally, etc
Take by mouth.., Give, Chew, Swallow whole, etc.
Number of dosage units per dose
(Take one tablet, Give two teaspoonfuls, etc).
Frequency of dosing (every six hours, once a day, etc.)
Patient lifestyle, inpatient schedules (compliance)
Duration of dosing (...for seven days,... until gone, ...if needed for
pain).
Purpose of medication for pain, for asthma, for headache, etc.
Avoid As directed
Special instructions (shake well, refrigerate etc.)
Warnings
Refills and Date Prescribed
Indicate either no refills or the number of refills you
want (dont leave it blank)
Date the prescription
All prescriptions expire after one year
Schedule II drugs can only be dispensed within 6
months of date on RX
Signature of the Prescriber

This makes the prescription a legal document

Include your degree
One signature line
You must write brand necessary or brand medically
necessary to get non-generic agent.
Electronic Rxs coming!
D.E.A. Registration Number

Drug Enforcement Agency (DEA)-US Government

Also enforced by Texas Dept. Public Safety (DPS)
DEA# is needed on any controlled substance (CII-CV)
Communicate Before You
Medicate!
Tell patient the name of the drug and what it is for.
Tell your patient exactly how to use the medication
Warn them of possible problems
What to do if dose is missed
Cost (source?) and storage
Review Rx for possible for errors
Common Abbreviations
qd or od = every day po = by mouth (orally)
qod = every other day IV = intravenous
bid = twice daily IV push or bolus = at one time
tid = thrice daily IV infusion = infuse over time
qid = four times/day IM = intramuscular
ac = before meals stat = immediately
pc = after meals sq or sc = subcutaneous
hs or qhs = at bedtime sig = signa or signetur =
disp = dispense directions for use
prn = as needed
 Qod and qid can get mixed up; qod and qd can get
mixed up.
One solution is to write out once a day or once every
other day or four times daily.
This brings up the confusion between q6h and qid.
Does this medication require a strict 6-hour dosing
interval?
Or, can it be given four times daily, for example, in a
6:30 AM to 11:00 PM day?
 Telephone Orders
Telephone orders may be placed for drugs in Schedules III, IV, and V.
A written prescription is required for ordering drugs in Schedule II.
In an emergency, a prescription for Schedule II drugs may be telephoned to
a pharmacy. If the pharmacy is willing to accept the telephone order, only
enough drug to cover the emergency may be prescribed. The physician is
then required to supply a written prescription to the pharmacy within 72
hours. The pharmacist is required to call the "Feds" if he doesn't receive the
prescription within 72 hours.
"Emergency" means that the immediate administration of the drug is
necessary to proper treatment, that no alternative treatment is available,
and that it is not possible for the physician to provide a written prescription
order for the drug at that time.
Risk Management Strategies for Prescribers

BE PROFESSIONAL AND COURTEOUS

KEEP GOOD RECORDS
PROVIDE ADEQUATE AND INFORMED CONSENT
TELL AND ALLOW PATIENTS TO CALL WHEN NECESSARY
PROVIDE THE PATIENT WITH A REALISTIC ASSESSMENT OF
OUTCOME, BENEFIT, AND ADVERSE REACTIONS
DO NOT SUPPORT FALSE EXPECTATIONS
Lets Write the Prescription!
 John Smith
4/12/10

25 Ankle sprain
NKDA

Motrin 600 mg tablet

50 tabs

one po Three times daily PRN Pain

1
Catherine Marco, MD

Catherine Marco, MD
Questions?