Prescription Recording Procedure

PRESCRIPTION RECORDING PROCEDURE

INTRODUCTION

The purpose of this procedure is to set out the method of issuing both initial and repeat prescriptions, and to specify the method by which prescriptions are recorded within the Practice.

COMPUTERISED PRESCRIPTIONS

• It is practice policy that, so far as possible, all prescriptions are issued and printed electronically. This ensures that the medication history in the patient’s electronic record is always up-to-date and available to all clinicians in the practice, and that clinicians are alerted by the system to adverse reactions and contra-indications.

• Where it is not possible to generate the prescription electronically (for example when a patient is seen at home) the clinician nevertheless has a duty to record details of the prescription issued in the patient’s clinical record as soon as possible after the visit.

• Administration staff are responsible for producing printed patient summaries [ordownloading patient details]for clinicians to take with them on home visits. These details must include adverse reactions to medication.

• Post-it notes and scraps of paper are inclined to get lost. Ideally, clinicians should record details of hand-written prescriptions on the printed patient summaries for later entry into the electronic record.

In general, the following procedure will take place:

• All prescription recording is entered in the patient record on the clinical system.
• When a prescription is issued in the surgery it is recorded on the clinical system in the medical record under medications.
• The record will state the prescription details and the date of issue.
• The issuer will enter each drug as current, acute or repeat and will link the medication to a clinical problem. The opportunity will also generally be taken to ensure that all repeat drugs on the patient record are linked to an appropriate clinical problem (‘problem linkage’ on medication screen)

Nurse-Initiated Prescriptions.

• When a prescription is initiated by a nurse it is entered in the patient record when the prescription is printed.
• The prescription is then checked and signed by the GP.

MANUAL PRESCRIPTIONS

• Hand written prescriptions are used on GPs’ visits.
• The GP notes any prescription issued onto the patients summary sheet, which they have with them at the visit, and notes that the prescription was hand written.
• . The prescription will then be added to the patients electronic record as per computerised prescriptions by the visiting GP and issued as a handwritten prescription (H) instead of being printed.

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