LEARNING OBJECTIVE: Recall the parts of a prescription, authorized prescribers and how prescriptions are written, filled, verified, labeled, andfiled.
The most important tool used by the pharmacy is the prescription. A prescription is a written or computerized order from a healthcare provider (prescriber) directing the pharmacy to compound and dispense a drug or medication for a patient to use.
Of special importance is your understanding and conformance to the following protocols:
· All information pertaining to a prescription is confidential and should not be divulged to any persons not specifically involved in the treatment.
· No prescription or any of its parts may be applied or transferred to any person other than the patient specified.
To fill a prescription correctly, you must thoroughly understand the prescription writing and filling process. Because regulations and policies governing pharmacies sometimes change, it is important for you to be familiar with pharmacy policies in the Manual of the Medical Department (MANMED), NAVMED P-117. The MANMED is the basic guide to pharmacy operations.
PARTS OF THE PRESCRIPTION
Currently, there are two standardized forms used for prescriptions: the DoD Prescription, DD Form1289 (fig. 6-3) and the Polyprescription, NAVMED 6710/6 (fig. 6-4). Information placed on these forms must be either typewritten or legibly handwritten in ink or indelible pencil. In addition to these two forms, many of today’s fixed medical facilities (e.g., naval hospitals and medical clinics) now have automated pharmacy systems that allow healthcare providers to enter prescription requests into computers in their offices instead of handwriting prescriptions. Prescriptions, written or computerized, have, for the most part, the same information requirements. The only major difference is that automated prescriptions do not require the prescriber’s signature.
DD 1289 is used extensively for outpatient prescriptions. For this reason, the key parts of DD 1289 will be discussed in the following sections. See figure 6-3 for examples of specific block entries.
Patient Information Block
In the patient information block, located at the top ofthe DD 1289, the patient’s full name and date ofbirth are required. At most medical facilities, however, additional patient information is added to this block. This additional information usually includes the patient’s duty station; social security number with family member prefix; rate; and branch of service.
Medical Facility and Date Block
The medical facility block, located below the patient information block, should contain the name of the medical facility or ship where the prescription was written. Completion of this block is important if the source of the prescription needs to be traced.
The date block, located to the right of the medical facility block, should contain the date in which the prescription was written.
The large block in the center of the DD 1289 is the prescription block. It contains four parts: the superscription, the inscription, the subscription, and the signa.
SUPERSCRIPTION.—The superscription “Rx” means “take” or “take thou” or, in effect, “I want this patient to have the following medication.”
INSCRIPTION.—The inscription is that part of the prescription that lists the names and quantities of the ingredients to be used. This part of the prescription
is of utmost importance, since the spelling of many unrelated drugs is similar. Whenever there is doubt as to the drug or the amount listed in the inscription, the individual filling the prescription should always verify the inscription with the prescriber.
SUBSCRIPTION.—The subscription follows the inscription and is that part of the prescription that gives directions to the compounder.
Figure 6-3.— Prescription form.
Figure 6-4.—Polyprescription form.
SIGNA.—The signa, not to be confused with the prescriber’s signature, is the part of the prescription that gives the directions for the patient. This portion is preceded by the abbreviation “Sig.”
Prescriber Signature Block
Finally, the prescriber signature block, located at the bottom of the form, must contain a legible signature of the prescriber, as well as the prescriber’s full name, rank, corps, and service, stamped, typed, or handprinted. Mimeographed, preprinted, or rubber-stamped prescriptions may be used, but signatures must be original and in the handwriting of the prescriber. Facsimiles are not acceptable.
According to the MANMED, the following persons are authorized to write prescriptions:
Prescriptions written by civilian prescribers, other than those employed by the Navy, may be filled for authorized beneficiaries, provided the prescribed item is on the medical facility’s formulary (a published listing of medications) and the prescribed quantity is within limitations established by the command.
With the exception of the polyprescription, prescriptions are limited to one item per prescription. The quantity of the drug prescribed should be a reasonable amount needed by the patient. Excessive or unrealistic quantities should not be prescribed. Erasures on prescriptions are prohibited, and interlineations (information inserted between lines of writing) must be initialed.
Finally, persons authorized to prescribe cannot write prescriptions for themselves or members of their immediate families.
When you receive a prescription for filling, you should follow certain basic steps to make sure that the right patient gets the right medicine in the right amount in the right way. There are no shortcuts—in the pharmacy things are done right or not at all!
First of all, satisfy yourself that the prescription you have received is a bonafide one and that the person you have received it from is entitled to have it filled by your pharmacy. You don’t need to be tedious about verification. The simplest and best way is to ask for an ID card and verify the expiration date on the ID card.
Study the prescription carefully and make sure that the drug prescribed is reasonable, that its amount or dosage is realistic in consideration of the patient’s age, and that the quantity of the medication is practical. A prescription calling for 1,000 tetracycline tablets or a pint of paregoric, for example, warrants further inquiry.
If, in the process of verification, you feel that there is a discrepancy, an ambiguity, or an incompatibility, or for any reason you find it is necessary to consult the prescriber, never allow the patient to suspect that anything is amiss. You should never fill a prescription you do not completely understand or that you feel is incorrect. What appears to be an overdose may be the desired dose for a specific patient, but the prescriber will appreciate being called for verification.
When you are sure you understand the prescription and are satisfied that it is in all respects correct, you should give its filling your undivided attention. Most mistakes are made when the person filling the prescription is either interrupted while doing so or is trying to accomplish more than one task at a time.
During the process of filling a prescription, the label on the containers used in filling the prescription should be verified at least three times. Initially, the label should be read when the container is taken from the shelf. Then it should be read again when the contents are removed from the container. And finally, the container’s label should be read before it is returned to the shelf. By following these three verification steps for each prescription you fill, youwill reduce the possibility of making a prescription error.
Proper labeling of a prescription is as important as filling it correctly. It is reasonable to assume that if a great deal of accuracy is necessary to properly compound a prescription, it is just as important that the patient take the correct amount of medication in the right manner to receive its maximum benefits. Improperly written or misunderstood directions on a prescription label can be disastrous. Make sure all labels are typed clearly and their directions translated into simple layman’s language. Keep in mind that the prescription label serves two purposes. First and most important, it gives the patient directions pertaining to the medication; second, in case of misuse or error, it is the quickest means by which the contents of the prescription container, the person who wrote the prescription, and the person who filled it can be traced. Consequently, the following information, illustrated in figure 6-5, should always be on the label:
Other information that may need to be attached to the prescription container are labels reading “Shake Well Before Using” or “For External Use Only.” “Poison” labels should be omitted when a preparation is intended for external use, as many physicians prefer the “For External Use Only” labels.
Figure 6-5.—Prescription label.
After the prescription is labeled, check the ingredients again by some systematic method to ensure accuracy.
As an added precaution and to aid expeditious identification of drugs in case of undesirable effects, note the manufacturer and the lot number of the proprietary drug dispensed on the prescription form (fig. 6-3). This procedure, however, does not apply to medications consisting of a mixture of several ingredients. The initials or the code of the person filling the prescription must also be written on the prescription form (fig. 6-3).
Prescriptions that have been filled must be maintained in one of several separate files:
Currently, prescriptions are required to be kept on file for at least 2 years after the date of issue.
LEARNING OBJECTIVE: Recall Hospital Corpsman responsibilities and accountability pertaining to controlled substances; identify controlled substance schedules; and recall controlled substance security, custody, inventory, and survey procedures.
medical technicians who handle controlled substances and other drugs are held responsible for the proper distribution and custody of those substances and drugs. Nowhere is the demand for strict integrity more important. Misuse, abuse, loss, and theft of these substances have always, sooner or later, ended in tragedy and severe consequences. No one has ever profited by their misappropriation.
It behooves every Hospital Corpsman to thoroughly understand the responsibility concerning the custody and handling of controlled substances and other drugs and to be familiar with the regulations and laws pertaining to them.
Although the MANMED specifically assigns custodial responsibility for controlled substances, alcohol, and dangerous drugs to a commissioned officer (and more specific control to the Nursing Service), you, as a Hospital Corpsman, have the responsibilities of administering and securing them properly. All controlled substances and other drugs are to be kept under lock and key. Neither keys nor drugs should ever be entrusted to a patient.
Hospital Corps personnel are held accountable for drugs entrusted to them. Great care should be exercised to prevent the loss or unauthorized use of drugs. No drug shouldbe administered without proper authority. In addition, U.S. Navy Regulations forbid the introduction, possession, use, sale, or other transfer of marijuana, narcotic substances, or other controlled substances.
CONTROLLED SUBSTANCE SCHEDULES
Controlled substances and drugs require special handling and security measures. The Controlled Substance Act of 1970 established five schedules (categories) related to a drug’s potential for abuse, medical usefulness, and degree of dependency, if abused.
Controlled substances may migrate between schedules, and new products may be added. These changes will be promulgated by the Navy Materiel Support Command in the Medical and Dental Materiel Bulletin.
Schedule I substances have high abuse potential and no accepted medical use (e.g., heroin, marijuana, LSD).
Schedule II substances have high abuse potential and severe psychological and/or physical dependence liability. Examples of schedule II substances include narcotics, amphetamines, and barbiturates. Prescriptions for schedule II substances can never be ordered with refills and must be filled within 7 days of the date originally written.
Schedule III substances have less abuse potential than schedule II substances and moderate dependence liability. Examples of schedule III substances include nonbarbiturate sedatives, nonamphetamine stimulants, and medications that contain a limited quantity of certain narcotics. Prescriptions must be filled within 30 days of the date written and may be refilled up to five times within 6 months.
Schedule IV substances have less abuse potential than schedule III substances and limited dependence liability. Prescriptions must be filled within 30 days of the date written and may be refilled up to five times within a 6-month period.
Schedule V substances have limited abuse potential. Schedule V substances are primarily antitussives or antidiarrheals that contain small amounts of narcotics (codeine). Prescriptions must be filled within 30 days of the date written and may be refilled up to five times within 6 months.
Poisonous drugs, chemicals, and similar substances are classified as dangerous drugs. Because these substances are powerful, their containers should have a distinctive color, size, or shape, and the container should be placed in a special storage area so they are not mistaken for other drugs. In addition, the following safeguards should be enforced: