Prescription and referral making Yaser Baroud

Prescription writing Do no harm !!!

Prescription writing Write legibly in indelible ink Date the prescription and state the full name and address of the patient. All prescriptions should be signed by the prescriber.  Age of the patient

ELEMENTS OF THE PRESCRIPTION 1- Name and address of the prescriber (telephone n.) !! 2- Patient’s name, age, sex, address and date. 3- Superscription: It consists of Latin symbol Rx meaning take thau or you take

ELEMENTS OF THE PRESCRIPTION 4- Inscription : It is the principal part or body of the prescription which specify the medication, its strength, the dosage and direction for use by the patients. 5- Subscription : This part of prescription consists of directions to the pharmacist for dispensing or preparing the prescription. (tablets , capsules., syrup)

ELEMENTS OF THE PRESCRIPTION 6- Patient instructions : When to take drugs? Precautions How ?? 7- Prescriber’s signature and registration number:

Prescription writing Write generics Avoid unnecessary use of decimal points (eg, 3 mg, not 3.0 mg). For quantities less than 1 gram, write in milligrams (eg, 500 mg, not 0.5 g). For quantities less than 1 milligram, write in micrograms (eg, 100 micrograms, not 0.1 mg). Don't abbreviate micrograms, nanograms or units Use millilitres (ml or mL) not cubic centimetres or cc.

Prescription writing Should preferably be written in English, without abbreviation but some Latin abbreviations are acceptable. stat = immediately p.r.n. = pro re nata = when required o.d. = omni die = every day o.n. = omni nocte = every night b.d. = bis die = twice daily t.d.s. = ter die sumendum = to be taken three times daily q.d.s. = quater die sumendum = to be taken four times daily

Prescription writing PO (by mouth) PR (per rectum) IM (intramuscular) IV (intravenous) ID (intradermal) IN (intranasal) TP (topical) SL (sublingual) IP (intraperitoneal

Prescription writing For p.r.n dosage, state minimum dose interval and maximum total amount. Mention the number of days of treatment. Specify the strength and quantity (dose). Avoid abbreviations of drug names and preparations as these can be misinterpreted. Unused space must be cancelled

Referral making

Objectives know when to refer a patient to a specialist Be able to write a competent referral letter keep good records of the referral.

((However good your diagnostic abilities are, and however skilled you are as a clinician, there will come a time when you need to refer a patient to a specialist. ))

Referral is made by letters or online. If referring by letter then this should be thorough, providing the second clinician with a detailed history and the results of your examination

Referral must include Name, address, date of birth of the patient Description of the patient’s problem/symptoms History of the problem The results of your examination The results of any special tests you have performed Your provisional diagnosis, if any The medical history All relevant radiographs or investigations

The letter should be word-processed wherever possible, rather than hand-written, to ensure accuracy. A copy of the referral letter should be kept with the patient’s records Radiographs which may be of relevance to the current problem should be supplied with the referral letter.

Consultation form Patient name: Age: Date: Dear Dr., Refer to you the above mentioned patient, who came to my clinic complaining of dental pain for 5 days. Upon examnation, the tooth/ teeth is/ are indicated for extraction under local aneasthesia (articaine 4%+ adrenaline 1: 100000) . Patient is hypertensive, diabetic on insulin (30 units *2) and he claimed that he underwent prosthetic valve replacement 2 years ago. For your kind opinion regarding fitness for the procedure, possible need for prophylaxis, and if there are other special precautions that should be considered perioperatively . Yours sincerely, Dr. Mahmoud Ahmad BDS / University of palestine 0599xxxxxxx Dr. MahmoudA. @ hotmail.com