The method of prescribing medicines applies to all instances of prescribing within NHS Tayside.

In order that there will be a complete record of all medicines prescribed during the patients stay in hospital, i.e. wards, theatre, labour room, or out-patient departments, all medicines and licensed wound management treatment prescribed for administration to a patient whilst in hospital (see definition in Introduction) MUST be entered sequentially on the Prescription Sheet. It is a requirement that oral, non-parenteral and parenteral prescriptions must be prescribed together starting from the top left page of the TPAR. They must NOT be separated to different ends of the TPAR. (THB(PN)024SS is the only exception to this).

Diagnostic agents used in Radiology are recorded in that Department.

Patients attending the Accident & Emergency Department have a record made of any medicines administered or supplied for use after discharge on the Casualty Record Sheet, THB (MR) 5A,Rev.

*It must be noted that if pre-operative medication is prescribed on the Anaesthesia Record Sheet, it is imperative that this is indicated in the space provided on THB (MR) 024SS/LS/DS Medicines Prescription Sheet or THB (MR) 47 Combined Medicine Prescription Sheet/Nursing Report - Day Cases.

The prescriber must sign to indicate which additional prescribing and recording charts are in use at the time of writing the TPAR. Once the additional chart is no longer in use this must be cancelled by placing a single line through the chart type and initialling this alteration. It must be noted that this section is potentially a very useful reminder to all users of the prescription chart and proper use can avoid errors, omissions or duplications. Also, this section runs for the duration of the chart and must be re-written along with the rest of the medication when appropriate.

Additional “Medicine Charts” that have the capacity to record the prescribers signature and the facility for the nurse to record medicine administration, only require the name of the drug, or the drug policy, to be stated on the TPAR with the statement “as charted” written across the administration boxes. If any policy medicines need to be excluded (i.e. Paracatemol in the symptomatic relief policy) the Prescriber must write “As charted except……” across the administration boxes.

When the chart in question is just a recording document then the TPAR needs to be completed as normal.

Parenteral infusions and additives must be prescribed as: “Parenteral infusions and additives as charted” in the regular medicines section of the TPAR. This is in addition to the prescribers signature on the front page of the TPAR.

The prescription must be based, whenever possible, on the patients informed consent and awareness of the purpose of the treatment.

Before use the Medicine Prescription Sheet THB (MR) 024SS/LS/DS must be completed in respect of all the patient personal details, e.g. name, date of birth, CHI number, etc. A patient “sticky” label may be used when available. Record the date of the current admission, even if this was weeks earlier.

19.5

Instructions for prescribers on the use of prescription sheets in hospital:
Medicine Allergies/Sensitivities

The Medicine/Other sensitivities section MUST be completed by the first clinician to use the chart. Additional sensitivities may be noted later as necessary. Use the widest definition of sensitivities (i.e. NSAIDS – GI bleeding, Transpore – Rash…etc). If it has been confirmed that a patient has No Known Allergies, (after discussion with patient and consulting medical notes) then the abbreviation NKA must be written in box 1 of the TPAR.

The sensitivities section must not be blank. If left blank it MUST be assumed that questions regarding allergies have not been addressed.

The information must be verified and documented consistently throughout the patient's clinical record.  It is recommended that the information is updated throughout the patient's stay in hospital and communicated to all involved in the patient's care, and importantly on transfer and discharge.

If a patient develops an allergy during their hospital stay, the clinical record must be updated to reflect current allergy status. If a patient experiences an adverse reaction from medication a report must be submitted through the Adverse Incident Management System and a Yellow Card must be submitted to the Medicines and Healthcare Regulatory Agency.

Instructions for prescribers on the use of prescription sheets in hospital:
Height And Weight

Space is available on the front page of the TPAR to record the patient’s admission height.  It is recommended, where appropriate, that patients be weighed on admission, as this is needed to perform initial nutritional assessments as well as calculating important medicine dosages during a patient’s stay. This does not replace weight records in nursing notes.

It is the prescriber’s responsibility to ensure that only one Medicine Prescription Sheet THB (MR) 024SS/LS/DS is in use for the patient at any one time where possible. Multiple records increase the risk of errors therefore when further medication is required and there is no room on the current chart a new TPAR must be written.

Each TPAR must be dated when commenced and the original admission date recorded on each.

When all 20 regular slots on the short stay TPAR and all 18 slots on the long stay TPAR have been used, the remaining days must be crossed out and a new TPAR started. Each entry must indicate the date of the original prescription. Patients must have only one TPAR in use at any given time. In exceptional circumstances and with agreement between nursing, medical and pharmacy staff, two TPAR charts may be used for the same person, when the number of regular medications they require makes it inappropriate to use one TPAR chart.

Each entry on the sheet is a prescription.

Each entry must be printed legibly in block capitals, in black ink or otherwise so as to be indelible, dated and signed by the prescriber with their usual signature.  Independent/Supplementary Prescribers must annotate the prescription as such.

Latin or other abbreviations must not be used.  e.g. GTN - (Glyceryl Trinitrate); and Normal Saline or PRN shall NOT be used. Print instructions/frequency in full (e.g. THREE TIMES A DAY). It is acceptable to use 8 hourly as required in the as required section of the TPAR.

Instructions for prescribers on the use of prescription sheets in hospital:
Prescribing of Regular Medication

The patient’s regular medication must be prescribed in the Medicine/Form box on the Regular Therapy pages of the TPAR. An approved presciber must sign the prescription for each medicine, using his or her usual signature, and indicate the start date (i.e. the first date of prescription). This must be recorded as DAY/MONTH/YEAR and carried forward as new charts come into use. In the areas which receive a clinical pharmacy service, the pharmacist and/or pharmacy technician will use the box marked pharmacy to give advice regarding drug administration (i.e. with or after food), indicate the use of patient’s own drugs, identify non-stock medication etc. The pharmacist will sign this box to indicate their review of the prescription.

To indicate the times of administration the pre-printed times may be selected by drawing a circle round the time desired. To indicate an alternative time, cancel the pre-printed times using a cross out and enter the alternative in the right hand column using 24 hour clock format and draw a circle around this new time. Where more than six times of administration are required within a 24 hour period (i.e. 2hourly use of nebulisers) then consecutive prescribing slots on the recording chart may be used. The twelve times will then read 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24 in a line going down the page.

Prescribers must liaise with their wards Senior Charge Nurse, so that they prescribe regular medication at the appropriate time to coincide with nurse medication rounds in that particular ward.

Instructions for prescribers on the use of prescription sheets in hospital:
Medicines

Shall be prescribed by the generic or approved name. Brand names must only be used when recommended in the BNF.

Instructions for prescribers on the use of prescription sheets in hospital:
Dose

This must be clearly stated in whole numbers i.e. decimal points must be avoided.  Quantities of less than one gram shall be given in milligrams e.g. 500mg and not 0.5g and, similarly, quantities less than 1 milligram shall be prescribed as micrograms. There are exceptions to this rule where it would be inappropriate to prescribe in micrograms, e.g. 12.5mg .

Except for compound preparations, the use of ‘one tablet,’ ‘one capsule’ or ‘5mL’ must be avoided. Doses of liquid formulations must be prescribed as a dose.

Instructions for prescribers on the use of prescription sheets in hospital:
The Form

i.e. tablet, suppository, elixir etc. shall be entered in full.  In the case of modified release preparations, this must be stated.  This is to prevent confusion with products which are available in a variety of presentations.

Instructions for prescribers on the use of prescription sheets in hospital:
The Method Of Administration Or Site Of Application, e.g. the use of cream or drops etc., shall be entered in the appropriate column, and shall be abbreviated as follows –

Oral and other forms of administration shall be written in full e.g. if a drug is to be given after food, enter the method of administration as 'Oral, after Food'.

If the prescriber wishes the medicine to be administered by enteral feeding tubes, this must be prescribed in the routine section on the TPAR.  Only one route of administration per prescription is acceptable. 

Where the prescriber wishes the nurse to have discretion concerning the routine administration of a medicine on an “as required” basis, the prescriber must state the indication and give a clear statement of dose, maximum frequency, and the maximum dose to be administered in each 24 hour period. 

Instructions for prescribers on the use of prescription sheets in hospital:
Parenteral Medicines
The prescription must indicate clearly the site and route of administration.  Where appropriate, reference shall be made to the dose and volume relationship.  Where an infusion control device is in use this shall be clearly indicated (e.g. syringe driver).

19.19

A review and stop date for treatments of a specified duration, for example, antibiotics, must be given.

Instructions for prescribers on the use of prescription sheets in hospital:
Medical Gases
Medical gases are medicines and are subject to the same procedures as other medicines. In the case of oxygen, the administration device and the flow rate must be stated.  For nasal cannulae, the oxygen flow rate must be stated in litres per minute and for masks, the percentage oxygen concentration must be stated.

Instructions for prescribers on the use of prescription sheets in hospital:
Medicines Administered According To Treatment Protocols
e.g. Symptomatic Relief Policy, Post-Operative Pain Relief Policy, Wound Management Policy.  The prescription must state administration is according to the Policy and contain any details of dosing and time required by it.  Medicines to be excluded from the policy must be stated.

Instructions for prescribers on the use of prescription sheets in hospital:
Once Only Prescriptions  
Similar requirements to those detailed above shall be entered in the respective columns.

Instructions for prescribers on the use of prescription sheets in hospital:
Cancellation
Where a medicine is to be discontinued the prescriber must draw a single line through the prescription to be cancelled and sign and date.

The prescription must not be defaced. If a prescription requires to be amended in any way the original entry must be cancelled and a new prescription written. In all cases the original entry must remain legible.

Instructions for prescribers on the use of prescription sheets in hospital:
Other Prescription Sheets
All medicines must be prescribed on the Tayside Prescription and Administration Record (THB (MR) 024SS/LS/DS), including such medicines as Warfarin, insulin, morphine for PCA etc., for which extra prescribing detail, monitoring or day to day variation in dosage may be charted on other prescription sheets.

When a special prescription sheet is in use this must be indicated by signing in the appropriate named box, or reference shall be made in the appropriate regular prescription section of THB (MR) 024SS/LS/DS (e.g. Insulin - see variable dosage sheet).

The following special prescription forms are in current use:

Where a treatment is to be discontinued both the special prescription sheet and the Medicine Prescription Sheet THB (MR) 024SS/LS/DS must be cancelled by drawing a line through the appropriate medicine and sign and date the cancellation (see Section 19 (paragraph 19.24)).

Instructions for prescribers on the use of prescription sheets in hospital:
Telephoned Prescriptions
Instruction by telephone to a Registered Nurse or suitably qualified practitioner to administer a previously unprescribed substance is not acceptable (NMC Standards for Medicines Management ).

In exceptional circumstances, and where the medication has been previously prescribed and the prescriber is unable to issue a new prescription, the use of approved information technology that allows the secure transmission of patient information between appropriately authorised staff may be employed.

In such situations, the Registered Nurse or suitably qualified practitioner must write these instructions on the prescription sheet in the ONCE ONLY section.  This must be followed up by a new prescription confirming the changes within a given time period.  The NMC suggests a maximum of 24 hours.

The Prescriber must follow up these  instructions as soon as possible by verifying the written message and signing the prescription within 24 hours.

Instructions for prescribers on the use of prescription sheets in hospital:
Telephoning and Faxing Prescriptions to the Pharmacy from Hospitals without a Pharmacy
This method of conveying discharge prescriptions must only be used when there is insufficient time available for sending a prescription by the normal route.  The local procedure must be followed.

In the case of a discharge prescription containing a Controlled Drug, it is a legal requirement that the original prescription be sent to pharmacy before dispensing.

Instructions for prescribers on the use of prescription sheets in hospital:
Electronic Prescribing - Also see Section 9, (paragraph 9.3)
With the advent of electronic prescribing, the method of writing and transmitting the prescription to the pharmacy will vary from the conditions set down. A policy must be developed locally wherever electronic prescribing is adopted.  This policy must incorporate the principles defined above.