PRESCRIPTIONS CHAPTER 5

CHAPTER OUTLINE  Prescriptions  Pharmacy Abbreviations  Prescription Information  The Fill Process  Labels  HIPPA  Review

PRESCRIPTIONS Unrestricted – Medical Doctors (MD) – Doctors of Osteopathy (DO) In their field of practice – Dentists (DDS, DMD) – Veterinarians (DVM) – Podiatrists (DPM) – Opticians (OD) Limited to some states and based on protocols – Nurse Practitioners (NP) – Physician assistants (PA) – Pharmacists (RPh) A prescription is an instruction and an authorization from a medical practitioner to issue a drug or device to a patient.

DISPENSING PRESCRIPTIONS Community pharmacists – Dispense directly to the patient. – The patient is expected to administer the medication according to the pharmacist’s directions. Institutional pharmacies – Nursing staff generally administer medications to patients. – Patient charts are referred to prior to administration because they provide the most up-to-date physician instructions.

THE PRESCRIPTION PROCESS 1.A prescription is ordered by a prescriber. 2.The prescription arrives at the pharmacy.  The patient drops off the prescription, or the pharmacy receives the prescription directly from the prescriber.

THE PRESCRIPTION PROCESS, CONT’D 3.The pharmacy technician: Checks the prescription to make certain it is complete and authentic. Verifies that the patient is in the pharmacy database. Obtains and/or verifies the patient’s demographic, insurance, and allergy information. Verifies any special instructions, such as pick-up time and days supply.

4.The technician enters the prescription into the computer system.  The technician scans a copy of the prescription into the computer and keys data from the prescription into the system.  Safety and accuracy checks are completed as per pharmacy protocol. THE PRESCRIPTION PROCESS, CON’D

THE PRESCRIPTION PROCESS, CONT’D 5.Insurance and billing information is processed.  The computer system evaluates the data against stored information and process any third-party billing.  The pharmacy technician asks the pharmacist to check drug utilization review (DUR) messages such as regarding drug interactions.  If a claim is rejected, the technician reviews the reject message and resubmits the claim, as appropriate.

THE PRESCRIPTION PROCESS, CONT’D 6.Label is generated. Once the payment is approved by the third party, the computer generates a label, patient handout, and the patient co-payment amount. Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

THE PRESCRIPTION PROCESS, CONT’D 7.The pharmacy technician prepares the prescription by:  Selecting the appropriate medication and verifying the national Drug Code (NDC) number on the computer- generated medication label against the medication being dispensed.  Preparing the medication per the prescription (e.g., counting tablets or measuring liquid).  Packaging the medication in the appropriate container.  Placing the the computer-generated medication label on the prescription container.  Organizing everything for the pharmacist’s final check.

THE PRESCRIPTION PROCESS CONT’D 8.The pharmacist checks the prescription. The pharmacist performs a final safety and accuracy check and then signs off on the prescription. The pharmacy technician “bags” the approved prescription for patient sale and attaches a drug information sheet regarding indications, interactions, and possible side effects.

THE PRESCRIPTION PROCESS, CONT’D 9.Patient receives the prescription. The technician delivers the packaged prescription to the cash register area for patient pickup. At pickup, the technician checks to make sure the correct patient is picking up the correct medication. The patient or a representative signs the insurance log. If the patient has not signed the pharmacy’s notice of HIPAA compliance, they are given a copy and asked to sign that log.

THE PRESCSRIPTION PROCESS CONT’D 10.The pharmacist provides counseling. The technician calls the pharmacist to the counter to counsel the patient per OBRA ’90, other state or provincial statutes, and pharmacy protocol.

PHARMACY ABBREVIATIONS Most common abbreviations are for: – Route of administration – Dosage form – Time of administration – Measurement

ROUTES OF ADMINISTRATION ABBREVIATIONS a.d.= right ear a.s., a.l. = left ear a.u. = each ear o.d. = right eye os, ol = left eye o.u. = each eye p.o. = by mouth S.L. = sublingually, under the tongue top. = topically, locally p.r. = rectally p.v. = vaginally inh = inhalation, inhale per neb = by nebulizer SC, subc, = subcutaneous subq i.m., IM= intramuscular i.v., IV = intravenous i.v.p., IVP = intravenous push IVPB = intravenous piggyback Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

DOSAGE FORM ABBREVIATIONS tab.= tablet cap= capsule SR, XR, XL = slow/extended release sol= solution susp= suspension syr.= syrup liq.= liquid supp.= suppository crm= cream ung., oint= ointment

ADMINISTRATION TIME ABBREVIATIONS bid= two times a day tid= three times a day qid= four times a day a.m./q a.m.= morning/ each morning p.m.= afternoon or evening h.s.= at bedtime prn= as needed a.c.= before meals p.c. = after meals stat.= immediately, now q __ h = every __ hour(s) Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

MEASUREMENT ABBREVIATIONS i, ii, etc.= one, two, etc. ss= one-half gtt.= drop ml,., mL = milliliter, millilitre Tsp.= teaspoon (=5 ml) Tbsp.= tablespoon (=15 ml) fl. oz.= fluid ounce (= 30 ml) l, L = liter, Litre mcg., µg = microgram mg.= milligram g., G., gm. = gram mEq. = milliequivalent a.a. or aa= of each ad= to, up to aq. ad= add water up to qs, q.s. ad = add sufficient quantity to make Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

OTHER ABBREVIATIONS UTD= as directed NR, Ø = no refill DAW= dispense as written _ c, w= with s, w/o = without

EXAMPLESDrugRx Label Directions Synthroid ® 100 mcg tablets i po q am Take one tablet by mouth once daily in the morning azithromycin 250 mg tablets ii po today, i po daily days 2-5 Take two tablets by mouth today, then take one tablet once daily on days 2 through 5 Alphagan-P ® 0.1% eye drops i gtt q8h ou Instill one drop into each eye every 8 hours Advair Diskus ® 100/50 inh i po BID Inhale the contents of one blister, by mouth, twice daily. [Rinse mouth after use.]-Optional Enbrel ® 50 mg SC injection i q week Inject the contents of one syringe, subcutaneously, once weekly

THE ELEMENTS OF PRESCRIPTIONS Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

PRESCRIPTION INFORMATION SAFETY Is the patient’s full name clearly written on the prescription? Has a nickname or initial been used? Is the patient’s information on file (e.g., date of birth, address, insurance, allergy)? Is it current? Is the medication for an over-the-counter product? Is the prescription for a Schedule II controlled drug? Is the prescription current (i.,e., written in the past few weeks)? Is the drug available in the quantity requested? Does the prescription look suspicious in any way?

THE FILL PROCESS: SAFETY CONSIDERATIONS Is the prescription for a high-alert medication? Are the instructions logical? Are the directions clear? Are there look-alike names? Pay attention to warnings! – Call a pharmacist to evaluate each warning. Check against the original! Don’t add information!

CAUTION! Is the prescription for a high alert medication? – High-alert medications are known to cause significant harm to the patient if an error is made. Are the fill instructions logical? – Is it q pm or prn; 4 ml or.4 ml. Are the directions clear? – “Take two tablets daily” vs. “Take one tablet twice daily” vs. “Take two tablets once daily.” Are there look-alike names? – Is it: Janumet ® or Sinemet ® ? Zovirax ® or Zyvox ® ?

CAUTION! Pay attention to warnings! – When warning screens appear, call a pharmacist to evaluate each warning. Check against the original! – During the fill process, always refer to the original prescription first and then refer to the label. Don’t add information! – Never add information based on what you assume the prescriber meant. The prescriber has knowledge of the patient’s condition that you don’t.

THE PHARMACY TECHNICIAN’S ROLE Assisting the pharmacist in routine, technical aspects of prescription filling. Treating each patient, their personal information, and their medications with respect. Accepting new prescriptions from patients, obtaining all necessary information, and keying it into the computer. Alerting the pharmacist whenever a DUR warning screen appears while filling a prescription. Faxing or telephoning refills and clarification requests to prescribers.

THE PHARMACY TECHNICIAN’S ROLE CON’T Consulting formularies and responding appropriately to third- party adjudication messaging such as: non-preferred drug, prior authorization or step-edit required. Quickly locating the correct medication for dispensing, calculating quantities, repackaging medication, and locating the corresponding patient medication guide. Compounding a prescription under supervision. Recording the dispensing of controlled drugs.

THE PHARMACY TECHNICIAN’S ROLE CONT’D Checking the work of other technicians, as instructed by a pharmacist. Referring patients to a pharmacist for counseling on the use of prescription and over-the-counter medications, or any other question requiring judgment. ALWAYS ensuring the accuracy and safety of the prescription by incorporating quality control checks into every step in the process.

LABLES Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

RULES FOR WRITING DIRECTIONS FOR USE Start with a verb. – take, instill, inhale, insert, apply Indicate route of administration. – Apply to affected area. – Take one tablet by mouth. – Insert rectally. – Place one tablet under the tongue. Do not use abbreviations. Use familiar words. – teaspoonful or 5 ml

AUXILIARY LABELS

INSTITUTIONAL LABELS Unit dose packing is widely used in institutions such as hospitals and nursing homes. Contain only the following information: – name, strength, manufacturer, lot number, expiration date, and dosage form of the medications Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

PRESCRIPTION-TO-LABEL EXAMPLES Images copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

PRESSCRIPTION-TO-LABEL EXAMPLES CONT’D Images copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

lNSTITUTIONAL MEDICATION ORDER EXAMPLES Images copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

36 WHAT IS HIPAA? Health Insurance Portability and Accountability Act of Federal law enacted to: Ensure the privacy of an individual’s protected health information (PHI). Provide for individual rights regarding PHI. Provide security for electronic and physical exchange of PHI. Provide for the continuation of health insurance coverage for workers who leave their jobs.

37 PHI: PROTECTED HEALTH INFORMATION – Any personal information that could be used to identify an individual or their health history. – Includes patient’s: Name, address telephone, address. Medical diagnosis, medical records, and prescription drug history. Identifying numbers, including Social Security, insurance numbers, credit card account numbers. Birth date, dates of admission and discharge, or death. Payment records.