How to Write a Prescription

Key Elements 

• Name of medical practice at top of the pad
• Name of the patient with date, sometimes address and age and weight
• Rx: Name of med: legible and spelled right
• “Sig” (Often the abbreviation “sig” will appear just before the directions on the prescription. “Sig” is short for the Latin, signetur, or “let it be labeled.”) Amount, dose, route, how often, other instructions: “with food, around the clock, at bedtime etc.”
• Dispense: quantity (write out numeral for controlled substances and to prevent errors)
• Refills and generic options
• Signature

Note Commonly Used Medical Abbreviations

Schedule of Controlled Substances

• Schedule I – only for research (heroin and yes marijuana)
• Schedule II – no telephone Rx for outpatient; no refills  (morphine)
• Schedule III – rewrite Rx q 6 months or 5 refills; telephone Rx ok  (Tylenol #3, Vicodin)
• Schedule IV – low abuse potential relative to schedule III (alprazolam (Xanax), lorazepam (Ativan)
• Schedule V – low abuse potential relative to schedule IV; states may vary (Lomotil)

Documenting a Medication History/Regimen

Assess the following considerations when managing the patient’s medication profile:

• Allergies and effects: always clarify the reactions to medications and allergies.
• Adverse drug Rx: assess and monitor adverse reactions i.e. consistently use an AIMS screening tool.
• Ht/Wt, BP, pulse: for example track weight and other effects of psych medications to possibly switch or decrease dosages.
• Current drugs: dose, route, frequency, reason: being consistent and clear with the patient and expectations may increase adherence.
• Perceived efficacy: what’s the purpose/goal of medication treatment?
• Perceived ADRs: what are the risks of using a particular medication, regardless if it’s rare and DOCUMENT that the patient is aware of the risks.
• Adherence to regimen: document if the patient is or isn’t adherent (non-compliance is not used anymore) to medications and the reason or resolution.
• Nonprescription med use: alternative, OTC, and complimentary: sometimes non-medical treatment can cause damage or affect other medications.
• Pregnant or lactating: make sure the mother is aware of risks/harm to the fetus or newborn, also consider collaborating with the OB.
• Support systems if needed: for example including family members or caretakers to make sure an anti-psychotic med is given or if the child is less hyper in the classroom with medication therapy, do the teachers notice a difference. More involvement =’s more support.
• Financial resources: are the medications covered by insurance, is a generic form available, and is it cheaper to pay out of pocket? Always consider the patient’s finances and how to obtain affordable but quality care.
• Co-morbidities: does the patient’s heart medication i.e. beta-blocker worsen the depression, are the patient’s kidneys and liver still functioning or being monitored? How are the patient managing if they’re blind, had a stroke, gastric bypass surgery? Always consider collaborating with the PCP or people who specializes in cancer, for example, don’t try to move a mountain by yourself -the more complicated the case is, the more support is needed.
• Caffeine, nicotine, ETOH, illegal drug use: does the patient need to go to a treatment center? Are they at risk for a seizure disorder and liver problems? or possibly abusing medications? Try using non-scheduled medications if a person has addiction problems or is at risk.

Include in Patient Education

• Drug name (generic/trade)
• Purpose and expected action
• Proper use (route, dose, schedule)
• Common SE, how to treat, when to call the provider or seek help
• Interactions
• What to do if  a dose is missed
• Special precautions (driving etc., food, sedation)
• How many refills or the course of the pharmacotherapy, especially with scheduled medications