How to write a drug chart ... properly!

LECTURE EXTRACT FOR PHASE 3

Dr David Wood Consultant Physician and Clinical Toxicologist Guys and St Thomas NHS Foundation Trust, London

Key Steps in Prescribing

1. 2. 3. 4. Ensure it is the right patient Always write legibly Sign and date everything you do Check the allergy status before prescribing anything 5. Check that you arent duplicating prescriptions 6. If are unsure ask about or look up doses, frequencies and/or the drug you are prescribing 7. Take time when prescribing!

Area for patient identification

Use hospital sticker

If no stickers then write:

Name

Date of Birth
Hospital Number

ALLERGY SECTION MUST BE FILLED IN FOR EVERY PATIENT BEFORE YOU WRITE ANYTHING ELSE
Document what the allergy is

Sign and date the entry

Dont forget to alter entry if patient develops allergy

ONCE ONLY PRESCRIPTIONS

Always date AND time that you want drugs to be given First dose antibiotics should be prescribed here (Surviving Sepsis campaign) improves number given within an hour

ANTICOAGULANT PRESCRIBING
Ensure you check the INR result before prescribing Warfarin Be aware of the GSTFT anticoagulant guideline on how to correctly initiate and continue Warfarin therapy

Medicines Reconciliation
Nearly last page ..... but one of most important

Ensure accurate drug history prior to admission

GP Old letters (EPR)

Pharmacy help

Drugs Not Given

Usually completed by nursing staff
Indicates reason(s) for drugs not being given

Check on a regular basis is it because your patient is nil by mouth?

Regular Prescriptions: Key Components Part 1

Drug Name Dose

Route

Date of prescription

Duration of treatment

Signature (AND NAME)

Key Components Part 1

Check the patients name/allergy status first

Write legibly and preferably in block capitals

Use generic drug names not trade names Dose and route have to legible Sign and print you name for each prescription Do not abbreviate micrograms and units
Space between units and dose

Try not to use decimal points

Put a duration for drugs such as antibiotics

Regular Prescriptions: Key Components Part 2

Date for administration Area when administration is signed for

Pre-determine administration times

Space to enter own times

Regular Prescriptions: Key Components Part 2

Check the patients name/allergy status first Written legibly and preferably in block capitals

Clearly indicate times that you want drugs to be given

Tick times printed or legibly write times in yourself
Sign and date every time!

When crossing off medications

-

As Required Prescriptions:
Drug Name Dose

Route

Signature (AND NAME)

Date of prescription

Duration of treatment

As required prescriptions: Key Components

Check the patients name/allergy status first Check regular medication to ensure no duplication
E.g. Paracetamol and co-codamol

Write legibly and preferably in block capitals Use generic drug names not trade names Dose and route have to legible Sign and print you name for each prescription Do not abbreviate micrograms and units

Re-writing of Drug Charts

Check all drug charts every time you review your patients
Re-write charts yourselves
You know the patient More time during the day than out of hours

Shouldnt be an out of hours job

Extra work for colleagues

Increased risk of errors occurring

Summary
Prescribing is a complex process Make yourself familiar with the drug chart(s) used where you are working

Take time when prescribing

Try to ensure you minimise the risk of errors in the prescribing pathway occurring Know sources of advice and help when you are prescribing