11/13/24, 7\:44 PM Guide | Prescribing basics

Prescribing basics

Table of contents

Introduction

Prescribing is an important component of patient care, which unfortunately can very easily go awry. The dangerous nature of
prescription medications means that the process of prescribing is heavy regulated through legislation, clinical guidelines, local,
regional and national protocols. What may seem like a relatively simple and straightforward process can sometimes be much
more complex than it
Prescriptions represent a request from one healthcare professional to another to administer or supply medication to or for a
patient. Some medications do not require a prescription as they are considered safe enough for patients to use without
professional supervision and these are legally classi
less safe and require supervision by healthcare professionals are classi
POMs and can only be used under the supervision of a prescribing healthcare professional. Anything that is not a GSL or POM is
classi
Something you should consider
formats, from the technical methods that use ePrescribing systems or ‘regimen prescribing’ (where users click a button and
automatically prescribe a combination of medications) to handwritten prescription using pen and paper, or a combination of
both.
The technical aspects of the prescription will vary from place to place but there a few key elements of the prescription that will
remain the same, as these are required by law in the United Kingdom (namely the Medicines Act 1968, Misuse of Drugs Act
1971 and Pharmacy Order 2010). This is particularly true for products that are likely to be misused and require extra controls to
manage their supply. These products are known as controlled drugs and are grouped into schedules, from 1-5, where 1
indicates a high likelihood for abuse with little clinical application and 5 indicates a clear clinical application with a low
likelihood for abuse. This di
criminal possession of substances.

The patient

Any prescription must include the patient’s name. This information is used to identify the patient and ensure that the right
medication is given to the right patient. The address of the patient could be their residential address, care home or the ward the
patient is on. The age or date of birth of the patient is a useful way to identify the patient, however for patients under the age of
12 years it is a legal requirement to include the age or date of birth. Age is a useful indicator of liver and kidney function as
well as fat/water ratio which can alter the distribution, metabolism and elimination of medication from the body. This makes the
age of the patient an essential piece of information when deciding if medication is clinically suitable. This is particularly
important for children, hence the legal requirement, but also for elderly frail patients so including the age or date of birth of the
patient represents good clinical practice.

Summary

Full name
Address
Age or date of birth (must be included if the patient is under 12 years old)
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The medication

Just like the technical aspects of prescribing, what can be prescribed will depend on where you are working and your level of
training. Some medications can only be prescribed by healthcare professionals that are authorised to do so. This is typically the
case for very expensive medications or very dangerous medications, such as chemotherapy or intravenous immunoglobulin.
You should check that you are authorised to prescribe the medication(s) you are trying to prescribe. This can be done easily on
electronic systems, as the system may only let you select items you are authorised to prescribe, however, if using a manual
prescribing process you should check the following resources\:
Clinical supervisor
Practice or trust formulary
Local formulary - developed by local and regional drug and therapeutics committees and usually available online
Nurse Prescribers’ Formulary - for community nurse prescribers, available online
Dental Practitioners’ Formulary - for dentists, available online
Decisions about which medication should be prescribed should be shared with patients and carers. About 1 out of every 10
prescribed medications are never started and about 50% of medications are not taken as they’re prescribed. Including patients
in decisions about their care increases the likelihood that they will start and continue to take their medication.

Information that should be included on a prescription

Name of the drug
It is best practice to use the ‘generic’ or the actual name of the drug, rather than a branded product name, for most
medications. As this will be cheaper for pharmacies to supply.
However, some medications s h o u l d be prescribed using their branded name, particularly if they have a narrow therapeutic
range. This means that the metabolism, distribution and elimination may be di
For example, Lithium should be prescribed using the branded names of Priadel, Camcolit and Liskonum to ensure consistent
drug serum levels.
The name of the drug must be included for schedule 2 and 3 controlled drug prescriptions.
Formulation
This is the ‘form’ you would like the medication to be in and describes how the drug will get into the patient. For example, as
tablets, capsules, solution, elixir, suppository, pessary, cream, powder, pressurised inhaler, dry powder inhaler, subcutaneous
injection, intramuscular injection or infusion.
There are many formulations available for most medications and if you’re unsure about which formulation to prescribe you
should make a shared decision with the patient, if possible. If you’re not sure what form the medication takes, try and contact a
pharmacist or pharmacy technician, who should be able to
The formulation must be included for schedule 2 and 3 controlled drug prescriptions.
Strength
This is not the dose! The strength relates to how much drug is in the formulation you have requested. For example, 10mg
tablets or 5mg tablets.
The strength must be included for schedule 2 and 3 controlled drug prescriptions.
Dose or instructions
Historically, doses were written using Latin and over time these were abbreviated. For example, o m n i d i e or once a day is
abbreviated to OD. Many errors relating to prescriptions are caused by folks not just failing to read Latin, but failing to read
abbreviated Latin! For example, q u a t r o d i e or four times a day is abbreviated to QD, which can be misread as OD, if
handwritten, leading to sub-therapeutic doses. To avoid errors then, try to write doses using plain English such as once, twice,
three times (avoid thrice) or four times per day.
Doses can be ‘licensed’ or ‘unlicensed’
. Licensed doses have been approved by regulators who have assessed the evidence
for the product at a particular dose for a particular reason (or indication). Unlicensed doses or ‘o
approved and the evidence for use of the medication at that dose for that indication has not been assessed. When prescribing
‘o
The dose of the medication should be checked in reliable resources, such as an up to date copy of the British National
Formulary.
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Some medications require a loading dose to enable a therapeutic serum level to be established quickly. For example, Warfarin
requires the patient to be ‘loaded’ with a short term high dose followed by a longer-term lower dose. If you’re unsure if a
medication requires a loading dose, contact a pharmacist.
Additionally, some medications have narrow therapeutic ranges, this means that patients can quite quickly build up toxic
levels of the drug in their body and professionals need to monitor this. A very common example of this would be the Vitamin K
antagonist Warfarin, which we monitor using the International Normalised Ratio or INR for short. The t h e r a p e u t i c r a n g e of a
medication often depends on the indication and the patient, so make sure to check or set these for each prescription
individually. Other approaches to monitoring may focus on the patient's response to medication, for example monitoring white
cell counts with clozapine, liver enzymes with statins or renal function with angiotensin-converting enzyme inhibitors.
Antagonists that block receptors should be introduced at low doses and gradually increased and, when stopping treatment,
should typically be withdrawn slowly.
Dose or instructions must be included for schedule 2 and 3 controlled drug prescriptions.
Quantity
Quantity should be used to describe how long you would like the patient to use this medication. Many di
measure can be used (e.g. days, weeks, months) or the actual quantity of medication you would like to be supplied (e.g. 7
tablets).
For schedule 2 or 3 controlled drugs you must include the actual quantity of medication you would like supplied in words
and

Summary

To summarise, good prescribers include the following information\:
Name
Form
Strength
Dose
Quantity
Table 1\: Common controlled drugs used in practice Schedule
Morphine Schedule 2
Codeine Schedule 5
Tramadol Schedule 3
Pregabalin Schedule 3
Temazepam Schedule 3
Fentanyl Schedule 2
Oxycodone Schedule 2
Zopiclone Schedule 4 Part 1
Somatropin Schedule 4 Part 2
Cannabis Schedule 1

The professional

Many times as a junior prescriber you may be asked to sign a prescription, however, not every healthcare professional has the
authority to prescribe every medication. For example, junior doctors can not prescribe chemotherapy. During the signing of the
prescription, it is important that enough information is provided to create a record of which healthcare professional is
authorising the supply or administration of a medication. This enables prescribing practices to be audited and ensure that poor
practices are identi
Information about the prescriber that is required by the person signing the prescription is discussed below.
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Name

This should be legible and be your ‘professional name’
.

Authority to prescribe

This should indicate what quali
independent prescribing quali
within an organisation.
This could also be a registration number with statutory bodies that can be checked to verify a prescribers status, such as the
GMC, GPhC, GDC and NMC.

Date

This should include the date that the prescription was issued by the professional. This may be di
prescription should be started and if the prescription is to begin on a speci
the dose or instruction section of the prescription.
Prescriptions can be pre-dated (for a time in the future) but should not usually be post-dated (to cover a period of use in the
past) unless there are exceptional circumstances. For example, pharmacists can make supplies of medication legally if there is
an agreement for a prescription to be written within the next 24 hours.

What you need to decide\: patient safety

The therapeutic decision-making process is in
involve the patient and their carers, if possible.
All medication comes with side e
year. Whenever you’re prescribing medication, you should always consider the risk and bene
to do this is to consider the necessity of the medication.

Dosing

Once necessity has been identi
decision should be evidence-based but person-centred. For example, some randomised controlled trials will identify a
therapeutic dose, however, the participants in the trial may be very di
Most medications are prescribed according to actual body weight (mg/Kg) but beware of hydrophilic medications that require
dosing via ideal body weight, such as gentamicin.
Watch out for daily versus divided dosing (e.g. Paracetamol 15mg/Kg/dose or 60mg/kg/day).
Prescribing too much medication can lead to dose-dependent side e
use the smallest dose for the shortest period where possible.

Duration

After dosing, consider the duration. Does the medication require acute or chronic use? Is this acceptable to the patient?
This is a particularly useful consideration for treatments that can cause dependence such as opioids, benzodiazepines, z-drugs,
gabapentinoids as well medication where long-term use can lead to complications (e.g. corticosteroids) or resistance (e.g.
antimicrobials).

Interactions

Before
and how this newly prescription may interfere with absorption, distribution, metabolism and elimination of other medication.
This can be tricky as interactions can be signi
BNF, MedicinesComplete Interaction Checker and a pharmacist or pharmacy technician.

Monitoring

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The therapeutic e
symptoms as well as ordering and reviewing tests such as full blood count, liver and kidney function tests, eye tests, and lung
function tests.
When making a plan to monitor medication, always consider and identify who will do this and by when. Pharmacists can help in
monitoring long-term conditions and therapeutic outcomes, including making recommendations to deprescribe medications
which are no longer bene
Table 2\: Medications with a narrow therapeutic range
Warfarin
Theophylline
Phenytoin
Carbamazepine
Digoxin
Lithium
Clozapine
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