PRESCRIPTION WRITING

AND

RATIONAL PRESCRIBING

Chukwu Leo Clinton (M.B.B.S; MS.c; Ph.D).

Lecturer/Researcher, Chemotherapy/Endocrinology Unit,

Department of Pharmacology and Therapeutics,
Faculty of Basic Clinical Sciences, College of Medicine,
Chukwuemeka Odumegwu Ojukwu University Awka Campus,
Anambra State, Nigeria.
+2348037745373; [email protected]

SEPTEMBER, 2021
INTRODUCTION

For every sick patient, upon evaluation and diagnosis it is the duty of the practitioner to select
from a variety of therapeutic options available. Drugs, surgery, psychological approach,
radiation, physical therapy, health education, counseling, further consultation for second
opinions, referrals and even no therapy are some of the therapeutic options available. Drug
therapy is by far the one most frequently chosen of these therapeutic options. Drug therapy
will basically require the writing of a prescription. A written prescription is the prescriber’s order
to prepare or dispense a specific treatment, usually medication (drugs); for a specific ailment
meant for a specific patient. When a patient comes for a consultation, the physician or another
authorized health professional prescribes medications about 70% of the time. Do note that
though an average of one prescription can be written per consultation, more than one prescription
may equally be written during a single visit (per consultation).

DEFINITION - A prescription is as a written or electronic order, from a medical practitioner or

a designated agent to a pharmacist (or the pharmacy representative) for a particular medication
for a specific patient with a specific pathology. Prescriptions are said to be medico-legal
documents, hence utmost care should be employed during the writing of a prescription. All
components of a prescription should be complete. There is no global standard for the
prescriptions. While every country has its own regulations, states within a country may as well
have their own variations in prescription writing.

A most important embodiment of a prescription is that it should be legible and must indicate
precisely what should be given. It should be noted that till date, no standard format for
prescription has been agreed upon or thought of, however recently, the Medical Council of India
has proposed a format for the prescription.
It should also be noted that patient’s morbidity and mortality(s) have been witnessed to occur
from medication errors that is due to an error contained in the prescription (prescription errors).
This should be avoided and remain one of the aims of this write up.
RATIONAL PRESCRIBING

A series of rational steps are should be involved in writing a prescription. Such steps which are
very mandatory may include:

1. Making a specific diagnosis.

2. Considering the pathophysiologic implications of the diagnosis.

3. Due Selection of a specific therapeutic objective.

4. Selecting the drug(s) of choice.

5. Determination of an appropriate dosing regimen.

6. Plan for monitoring the administered drug’s action.

7. Plan a program of patient counselling and education.

1. Making a specific diagnosis: It is mandatory as well as very important that a specific

diagnosis though sometimes provisional, be made in the process of writing a prescription. This is
required to move to the next step. For example, in a patient with a probable diagnosis of
rheumatoid arthritis or peptic ulcer disease, the diagnosis and the reasoning underlying it should
be clear. This information should be shared with the patient. Prescriptions need not be based on
the desire to satisfy the patient’s psychological need for any type of therapy. Such practice are
usually unsatisfactory and may result in unnecessary adverse effects.

2. Considering the pathophysiologic implications of the diagnosis: The prescriber is usually

in a much better position to offer effective therapy if the disorder is well grasped. For example,
increasing knowledge about the causation of peptic ulcer disease (PUD) makes possible, the
more effective use of proton pump inhibitors, antibiotics and other anti-peptic ulcer agents used
in PUD treatment. The patient should be provided with the appropriate level and amount of
information about the pathophysiology. Many pharmacies, websites, and disease-oriented public
and private agencies (eg. American Heart Association, Arthritis Foundation, American Cancer
Society, etc) provide information sheets suitable for patients on specific ailments.

3. Due Selection of a specific therapeutic objective: A specific therapeutic objective is

mandatory and should be chosen for each of the pathophysiologic processes defined in the
preceding step.

Some of the therapeutic options available include the use of drugs, surgery, psychological
approach, radiation, physical therapy, health education, counseling, further consultation for
second opinions, referrals and even no therapy. For our primary case of rheumatoid arthritis,
relief of pain by reduction of the inflammatory process is one of the major therapeutic goals that
helps in identifying the drug groups that should be considered. For the PUD, drastic reduction of
HCL secretion and eradication of Helicobacter pylori infection by the use of specific agents
remain the primary considerations.

4. Selecting the drug(s) of choice: Since one or more drug groups may be suggested by each of
the therapeutic goals as specified above, selecting a drug of choice from among the available
groups follows from a consideration of the specific characteristics of the patient, the clinical
presentation and the drug(s) to be chosen too. Characteristics such as age, co-morbidity(s), and
other drugs being co-administered (because of the risk of duplicative therapy or drug-drug
interactions) for certain drugs, are extremely important in determining the most suitable drug(s)
for the patients complaint. In the example of the patient with probable rheumatoid arthritis, it
would be important to know whether the patient has a history of aspirin intolerance or ulcer
disease, whether the cost of medication is an especially important factor and the nature of the
patient’s insurance coverage, and whether there is a need for once-daily dosing. The above
information will enable the selection of a probable drug from the group of non-steroidal anti-
inflammatory drugs (NSAIDs) available. Ibuprofen or naproxen would be a very rational drug
choice if the patient does not have PUD but does have a need for low-cost treatment.

5. Determination of an appropriate dosing regimen: The dosing regimen is determined

primarily using the pharmacokinetic parameters of the drug (ADME). If the patient is known to
have a disease of an organ say the kidneys, which is required for the elimination of the selected
drug, adjustment of the average regimen is needed to achieve optimal elimination. For a drug
such as ibuprofen, which is mainly eliminated by the renal system, kidney function should be
assessed. But with a normal renal function, the half-life of ibuprofen (about 60 minutes) requires
administration three (tds) or four times (qds) daily. A dose of 400mg 3-4 times daily (qds) has
been in practice. However, we can go as low as 400mg 2 times daily (bd) .

6. Plan for monitoring the administered drug’s action: It is worthy of note that major
toxicities require immediate attention and this should be clearly explained to the patient. The
patient should be informed on the various drug effects that will be monitored and in what way
this includes laboratory tests (if necessary). Also the expected signs and symptoms that the
patient should report. The duration of therapy should be clearly informed especially for
conditions that call for a limited course of therapy (eg, most infections), so that the patient does
not stop taking the drug prematurely. He should be made to understand why the prescription does
need not to be renewed. For an arbitrary patient with rheumatoid arthritis, the need for
prolonged; perhaps indefinite - therapy should be explained, including how to obtain refills. The
prescriber should also specify any changes in the patient’s condition that would call for changes
in therapy. For example, in the patient with rheumatoid arthritis, development of gastrointestinal
bleeding would require an immediate change in drug therapy and a prompt workup of the
bleeding.

7. Plan a program of patient counselling and education: The entire health team headed by the
prescriber (the physician, MD), should be prepared to repeat, extend, and reinforce the
information given to the patient as often as necessary. In some centers, health education
counselors are meant to reinforce such education needs. The more toxic the prescribed drug, the
more is the importance of this educational program.

It is worthy of note that the importance of informing, educating and involving the patients in the
various steps above need not be over emphasized. Though, many pharmacies routinely provide
this type of information with each prescription attended to, the prescriber must not assume that
this will occur.

WRITING THE PRESCRIPTION PROPER

A written prescription is a legal document that should be prepared with optimal care. While there
are some variations from state to state, the prescription basically has 8-10 parts that will be
discussed in this article.

So all drug prescriptions are meant to consist of about eight parts (some may have up to ten):

1. The prescriber’s (the health professional) information.

2. The patient’s information.
3. Date prescribed.
4. The medication (the recipe, or treatment, Rx).
5. The signature (the patient instructions or Sig).
6. The dispensing instructions (how much medication to be dispensed to the patient).
7. The number of refills (or Rf).
8. The prescriber’s signature (including his or her National Provider Identifier and/or Drug
Enforcement Agency number). In Nigeria, this number may represent the doctor’s Folio
or Registration No with Medical and Dental Council of Nigeria (MDCN).

THE PRESCRIBER’S (THE HEALTH PROFESSIONAL) INFORMATION)

This information is usually found at the top of the prescription sheet and normally consists of the
prescribing doctor’s name, office address, and contact information (usually the office or
clinicians’ telephone number). This very information may be seen on the hospital or doctor’s
letter headed paper as well. Some states require the doctor's state license number to be on the
form. It is not recommended that you preprint your Drug Enforcement Administration (DEA)
number on the prescription pad. It may become easy for drug abusers to lift a few prescription
forms for illicit use if that number is easily available. The DEA number is only required for
controlled prescriptions, though many pharmacies may request the DEA number with a
prescription to help when filing the patient's medication insurance claims.

PATIENT INFORMATION
The patient’s information can be seen below the prescriber’s information. Basically, this section
will include the patient’s full name (first and last names), age, and date of birth. Many names
such as "Smith" and "Jones" should include the complete name and address to help distinguish
patients with similar names. Sometimes the patient’s home address will be found here, as well.
An address is required on schedule II controlled drugs and should be included on prescriptions
for all controlled substances.

When the exact age is unavailable the word "adult" may be used in the age slot. This is more in
the undeveloped countries. Children and the elderly may need their weights enlisted when oral
medications and others are prescribed.

DATE PRESCRIBED

The date, as a part of the legal document confirms when the prescription was written.
Pharmacists are often presented prescriptions with dates that are well past the prescribing date.
Some patients elect to save prescriptions for future use. This often includes antihistamines and
antibiotics that may not be indicated or are even dangerous for the patient's present condition.
This and other reasons make date inclusion very mandatory.

RECIPE (Rx)

The recipe should include the drug (medication) being prescribed, its dose, and its dosage form.
For example, if you are prescribing 1000 milligrams (mg) tablets of acetaminophen
(Paracetamol), you would write “acetaminophen 1000 mg tablets” or “acetaminophen 500 mg
tabs.”

SIGNATURE (Sig)

This aspect contains the instructions given on how to take the medication. Above all, the
information should include information on how to take the drug (directions), how much to take it
(grams/quantity), and how often to take it (frequency). They are the doctor's instructions to the
pharmacist indicating how the patient should use the medication. Latin or English abbreviations
are used to provide specific instructions able to be translated by the pharmacist for patient use.
Typical instructions on the prescription would follow in this order: For example, if you would
like your patient to take one 500 mg tablet of Amoxicillin every six hours, you will have to
write: “Take 1 tablet by mouth every six hours” or, using abbreviations, “Amoxicillin 1 tab PO
q6h.” or Caps. Amoxicillin 500mg PO qds.

2 gtt q2h OD for 3 day: These instructions as used on a prescription for Ciloxan would be
interpreted as follows: two drops every 2 hours instilled in the right eye for 3 days.
Let’s say that you would like your patient to be able to take one 1000 mg tablet of
acetaminophen every six hours when he has headache. In that case, your write up should read,
“Take 1 tablet by mouth every six hours as needed for a headache” or “2 tabs. PO q6h PRN
headache.”

1 tab PO BID for 14 days: These instructions as used on a prescription for doxycycline would
be interpreted as follows: one tablet by mouth two times per day for 14 days.

1 gt QID OU for 7 days, then BID for 14 days, for itchy eyes SHAKE: These instructions as
used on a prescription for Livostin (levocabastine HCl, Ciba Vision Ophthalmics) would be
interpreted as follows: one drop of Livostin four times per day in each eye for 7 days and then
decreased to two times per day for 14 days, for itchy eyes caused by allergies; shake drops before
use.

For as-needed or pro re nata (PRN) prescriptions, you should indicate that the prescription is
PRN (as at when needed) and describe the conditions under which your patient can take the
prescribed medication. Note that writing your prescription as a PRN order essentially gives the
patient the option to take the drug when needed.
These instructions should be as specific as possible. Poor instructions given in the office and on
the prescription may lead to poor compliance and often improper use of the medication. It is
appropriate to write what the medication is being prescribed for in the signature to let the patient
know the indications for the medication.

DISPENSING INSTRUCTIONS (DISP)

The dispensing instruction is the next to be considered. This instruction will inform/help the
dispensing pharmacist to know how much medication you want like your patient to receive. You
should also include the amount of drug to be dispensed and the very form in which it should be
released to your patient. You have to also be sure to write out any numbers you use here clearly
to minimize the risk of a medication error. For our Amoxicillin example, if you would like your
patient to receive a one-week supply (or 28 tablets) of the medication, you would write “28
(twenty-eight) tablets” or “28 (twenty-eight) tabs.”

NUMBER OF REFILLS / REFILL DATA (Rf)

After the dispensing instructions, specify how many times you would like your patient to use this
prescription to refill his or her medication. Be sure to write out again any numbers you use. If
you do not want to prescribe any refills, write “zero refills.” Schedule II controlled substances
have no refills.

Most antibiotic and steroid prescriptions need no refills or one refill. For our hypothetical
acetaminophen example, if you are prescribing one refill, you would write “1 (one) refill.”
Glaucoma medications usually have three refills, which may allow the patient enough
medication for 3 to 6 months, depending on the size of the bottles dispensed. Schedule III
through V controlled substances can have five refills or can be refilled for a maximum of 6
months, whichever comes first. In eye care there is seldom a reason to have more than one refill
on these controlled drugs. This is not very well practiced in our practice in our environment;
rather we prefer to give such a patient a check-up appointment.

PRESCRIBERS’ SIGNATURE
At the bottom of the prescription, the prescribing clinician is expected to write his name as well
as sign the prescription. You may need to include your National Provider Identifier (NPI) in this
section. In our country Nigeria, this may represent our Folio or Registration number with the
MDCN. For controlled substances, you may be expected to include your Drug Enforcement
Agency Number. All these information are necessary for the pharmacy department to clearly
verify your prescription more easily.
OTHER INFORMATION MAY INCLUDE:

SUPERSCRIPTION (Rx)
This means a doctor’s prescription. This is the Rx symbol on the prescription form that
designates the written document to be a prescription. Rx is an abbreviation for a Latin phrase that
means "take thou of". It is also the Roman symbol for Jupiter and is presumably intended to
invoke his help in making the prescription effective in the cure of disease.

INSCRIPTION

This in a prescription includes the drug name, concentration and type of preparation. As drug
names should not be abbreviated, also correct spelling is very important to assure that the correct
medication is dispensed. Tobra Dex (tobramycin and dexamethasone, Alcon) and Maxitrol
(neomycin and polymyxin b sulfates and dexamethasone, Alcon) are examples of drugs that are
prepared in ointment (ung) or drop (gt) form.

Cortisporin (neomycin and polymyxin B sulfates, bacitracin zinc and hydrocortisone, Glaxo
Wellcome) comes in ophthalmic and otic (ear drops) preparations. Specify clearly which
preparation you wish the patient to use.

Drug names can be written using the chemical name, such as ciprofloxacin 0.3% (Ciloxan,
Alcon) or the proprietary form that requests a specific brand name drug. This preparation is still
under patent, so if you use either name the pharmacy will provide the product manufactured by
Alcon. Tobramycin has recently come off patent. If you prescribe "Tobrex" the patient should
receive the drug manufactured by Alcon unless you check the box on the prescription stating
generics are acceptable. If you write "tobramycin," the patient will likely receive the generic
form of the drug.

A drug is off patent if it is “no longer subject to patent restrictions”. Drug Patent: When a drug
is first developed by a pharmaceutical company to be used for a disease condition, such drug is
initially sold under a “Brand Name” by which the clinicians can prescribe it for use by their
patients. Such drug is said to enjoy Patent protection (covered under patent protection). This
means that only the Pharmaceutical Company that holds the Patent is allowed to manufacture
and market the drug to make profit from it.

Generic Drug: This refers to a drug created to be same as an existing approved Brand Name
drug in dosage form, strength, mechanisms of action and routes of administration, safety and
quality and performance characteristics. Generic medicine are expected to work the same as
Brand Name medicines.

For homatropine and pilocarpine: They come in different concentrations. So it is a good practice
to always specify the concentration, even if the drug comes in only one concentration. That drug
may likewise come in some other concentrations in the future. Concentration and preparation
form should be written just to the right of the drug name. Use the metric system of weights and
measures.

To avoid misinterpretation of the preparation strength, it is advisable to follow this standard in

writing percentages: If the percent is greater than one, with no fraction, do not use a zero after
the decimal, such as 1%. Writing 1.0% could easily be misread as 10%. On the other hand, if the
percent is less than one, do always precede the decimal with a zero, such as 0.1% or 0.05%.

Substitution permitted: Marking "Yes" allows the pharmacist to substitute a generic form of
the medication prescribed. Some notable health plans request that the generic drug be used to
save money. When writing the drug names remember that brand names are capitalized while
generic names are not capitalized: Pred Forte (Allergan) or prednisolone acetate 1%.

Subscription (Disp): Historically, this was an instruction to the pharmacist to compound

medications. This could include, for example, instructions regarding the fortification of
tobramycin for treating a corneal ulcer. Today, most medications are pre-compounded
preparations. Subscription now indicates the quantity of medication (number of capsules or
tablets) or the size of the bottle to be dispensed (5 mL, 10 mL, 15 mL).The subscription directs
the pharmacist or the dispenser what to make from ingredients i.e. mixture, liniment (pain-
relieving liquid rub), ointment etc and the quantity of the formulation to dispense. As said earlier,
these instructions may be entirely in English or with Latin abbreviations.

1. Typical examples of good prescriptions are shown below:

A typical chart order might be as follows: 06/09/2021; 10:30 a.m.

(1) Ampicillin 500 mg IV q6h 23 times; 5 days

(2) Aspirin 0.6 g per rectum q6h prn temp over 101F

2. Another example is in the figure below: (Figure adopted from an Article shared by Prithika S).

The modern prescription is written as simply as possible. It consists of a minimum number of

drugs, written in English, employs metric system and may use several abbreviations.
 POINTS TO REMEMBER

1. Always keep / document good records of medications prescribed, dates written, length of
treatment, concentration of medication and your diagnosis of the condition.

2. Illiteracy is the forgotten reason for noncompliance. If you suspect the patient cannot read or
may not be able to understand written instructions, check for understanding by having the patient
repeat the instructions verbally after you have explained how to use the medication. If possible,
explain the dosage and treatment plan to a family member.

3. When possible, explain dosage, diagnosis and the reason for the treatment to the available care
giver of the patient (spouse, parent, child, friend, nurse etc).

4. Explain specifically to the patient how to use the medication and why it should be used as such.

5. Written instructions should be given to the patient in the office when the dosage schedule is
complicated. When multiple medications are prescribed and when tapering of dosage is needed,
written instructions are especially important to achieve compliance.
A duly written prescription should be precise and completely finalizes the plan for improvement
of the health and welfare of your patient. Learning the system for writing prescriptions requires
actually writing them and reviewing the above guidelines to be sure the instructions and format
are correct.

ABBREVIATIONS
During prescription writing, a number of abbreviations of Latin words and phrases have been
used conventionally. But for a very few, most of them are gradually disappearing from the
prescription list of nowadays. Above all, while names of the drugs to be included in the
prescription should not be abbreviated, chemical formulas must not be used in prescription
writing so as to reduce the probability of error. The following is the list of some abbreviations
used in prescription writing. It is advisable to express the dosage regimens as mg/kg and time
intervals in hours e.g. q4h, q8h, q12h and q24h etc. to avoid the confusion in q.i.d., t.i.d., b.i.d
and s.i.d.

COMMON ROUTE ABBREVIATIONS FOR PRESCRIPTION

 PO (by mouth)
 PR (per rectum)
 IM (intramuscular)
 IV (intravenous)
 ID (intradermal)
 IN (intranasal)
 TP (topical)
 SL (sublingual)
 BUCC (buccal)
 IP (intraperitoneal).
 (Fig 1 Adopted
from an Article shared by Prithika S).
Other common abbreviations for prescription writing may include:

 daily (no abbreviation)

 every other day (no abbreviation)

 BID/b.i.d. (twice a day)

 TID/t.id. (three times a day)

 QID/q.i.d. (four times a day)

 QHS (every bedtime)

 Q4h (every 4 hours)

 Q4-6h (every 4 to 6 hours)

 QWK (every week).

It is worthy of note that whatever abbreviation you chose to adopt must be familiar to your
dispensing unit. This is especially so in Africa and other third world countries where most
medicine (drug) dispensers are not qualified pharmacists. Most of them are either trained nurses,
pharmacy technicians, CHEWs and SCHEWs (Community Health Extension Workers and
Senior CHEWs).

COMMON PRESCRIBING ERRORS These

errors may include but not limited to the following:

1. Wrong/Inappropriate drug (e.g., drugs that sound similar).

2. Wrong/Inappropriate dose. 4. Inappropriate units.

3. Poor/Illegible prescriptions. 5. Failure to take account of drug interactions.

6. Two drugs from the same class 7. Omissions.

8. Wrong/Multiple routes (IV/SC/PO). 9. Calculation errors (important in pediatrics).

10. Infusions with not clear/ enough details of diluent, rate, etc.

Prescribing clinicians and dispensing pharmacists are advised to be aware of these common
sources of errors in prescription writing so as to avoid patient’s morbidity and mortality’s which
may arise from such errors.

LEGAL CAPACITY TO WRITE PRESCRIPTIONS

In the USA and Canada, legislation governs who can write a prescription (national or local). In
the United States, physicians (any of M.D, D.O or D.P.M.) have the broadest prescriptive
authority. The district of Columbia allows licensed certified Physician Assistants (PA’s)
prescription authority in all 50 US states (in some states, limitations exist to controlled
substances). All the 50 USA states and the District of Columbia, Puerto Rico and Guam allows
registered certified nurse practitioners and advanced practicing registered nurses (such
as certified nurse-midwives) the power to write prescription (some states including limitations to
controlled substances). Some other health care professions also have prescription power only
related to their area of practice. Clinical pharmacists are allowed to prescribe in some states of
the USA via the use of a drug formulary or collaboration agreements. Florida pharmacists can
write prescriptions for a limited set of drugs. In all US states, optometrists prescribe medications
to treat certain eye diseases, and also issue spectacle and contact lens prescriptions for corrective
eyewear. Dentists and veterinarians have prescribing authority in all 50 US states and the District
of Columbia (confined only to their areas of practice). Several US states have passed treatment
legislations allowing clinical psychologists who are registered as medical psychologists and have
also undergone specialized training in script-writing, to prescribe drugs to treat emotional and
mental disorders. In the UK, some legislative changes allowed physiotherapists and podiatrists to
have independent prescribing authority for licensed medicines used to treat conditions within
their own area of expertise and competence in August 2013.
CLASSES OF PRESCRIPTION ORDERS
Prescription orders can be divided into two classes depending upon the availability of the
prescribed medications.
(i) Pre-compounded and

(ii) Extemporaneous or Compounded or Magistral (done unrehearsed/skilled/of expert ability).

A pre-compounded prescription order is one that calls for a drug or mixture of drugs supplied by
the pharmaceutical company by its official or proprietary name and pharmacist dispense same in
the form available without making any pharmaceutical alteration.

Example of pre-compounded prescription order: (Figure adopted from an Article shared by

Prithika S). For a dog: eg. Rx. Calamine lotion– 480 ml. Most of this type has been discussed
with above. Shake well before use and apply daily on skin lesions. Used for animal treatment
only. While in extemporaneous or compounded prescription, the clinician selects the drugs,
doses and form of the preparation that he/she desires and the pharmacist prepares the medication
accordingly. Done unrehearsed/skilled/of expert ability.
Examples of common extemporaneous or compounded prescription orders used in animal
treatment are listed below:
PRESCRIPITIONS FOR CHILDREN

It may be a legal requirement to include the age of the child on the prescription document. For
pediatric prescriptions, it may be advisable to include the age of the child if the patient is less
than twelve and the age and months if less than five. (In general, including the age on the
prescription is helpful.) Adding the weight of the child is also helpful. This is widely practiced in
Nigeria.
LABEL AND INSTRUCTIONS

USA prescriptions often have a "label" box. When checked, the physician instructs the
pharmacist to label the medication and provide information about the prescription itself is given
in addition to instructions on taking the medication. Otherwise, the patient is simply given the
instructions. Some prescriber’s further inform the patient and pharmacist by providing the
indication for the medication; i.e. what it is used to treat. This assists the pharmacist in checking
for errors as many common medications can be used for multiple medical conditions. Some
prescriptions will specify whether and how many "repeats" or "refills" are allowed; that is
whether the patient may obtain more of the same medication without getting a new prescription
from the medical practitioner. Regulations may restrict some types of drugs from being refilled.

E-PRESCRIBING

Handling prescriptions electronically is gaining momentum in most developed countries like the
USA. The USA congress had in the past passed legislation in support of this health care
initiative. E-prescribing provides an electronic flow of information between the prescriber,
intermediary, pharmacist, and health plan. It entails that the health plan can provide information
on patient eligibility, formulary, benefits, costs, and sometimes, a medication history. The
prescriber selects the medication, strength, dosage form, quantity, and directions for use and the
prescription is transmitted to the pharmacy where the appropriate data fields are populated. The
pharmacist now has the duty of reviewing the order and, if appropriate, dispenses the
prescription. The electronic system must be Health Insurance Portability and Accountability Act
(HIPAA)-compliant, and also requires a business association agreement between the pharmacy
and insurance plan involved.

PRESCRIBING ERRORS

It is very unfortunate that prescribing errors are common. Provided by several groups are online
information regarding practices designed to document such errors. Examples of such are the
National Coordinating Council for Medication Error Reporting and Prevention Program
(MERP; http://www.nccmerp.org/aboutNCCMERP.html) and Institute for Safe Medication
Practices (ISMP; http://www.ismp.org/).

COMMON PRESCIPTION ERRORS

A good prescription or chart order should contain sufficient information to permit the pharmacist
or nurse to discover possible errors before the drug is dispensed or administered. It is expected
that all prescription orders should be unambiguous, legible, dated (and timed in the case of a
chart order), and signed off clearly for optimal communication between prescriber, pharmacist,
and nurse. Certain types of prescribing errors are particularly common. These include errors
involving poor writing, omission of needed information perhaps leading to errors of drug dose or
timing; and even more dangerous is the prescription of inappropriate drugs for the specific
situation.

OMISSION OF INFORMATION

This form of errors are more common in very busy clinics with limited physicians as seen in
most undeveloped countries of the world. In most developed countries, a doctor has a specific
number of patients / clients to consult as well as specified working hours per working day. This
is unlike in the developing countries. Inadvertent sleeping at work from long work hours also
have its own toll. Errors of omission are common in hospital orders and may include
instructions to “resume pre-op meds,” which assumes that a full and accurate record of the “pre-
op meds” is available; “continue present IV fluids,” which fails to state exactly what fluids are to
be given, in what volume, and over what time period; or “continue eye drops,” which omits
mention of which eye is to be treated as well as the drug, concentration, and frequency of
administration. While chart orders may fail to discontinue a prior medication when a new one is
begun, it may also fail to state whether a regular or long-acting form is to be used. It may equally
fail to specify the strength or notation for long-acting forms; or may authorize “as needed” (prn)
use that fails to state what conditions will justify the need as appropriate.
CLASSIFICATION OF CONTROLLED SUBSTANCES (See the table containing listed
drugs below).

Who is authorized by Law to Prescribe Controlled Substances? Physicians, dentists,

podiatrists (care for the feet), or veterinarians have the traditionally responsibility and right to
prescribe drugs. Recently drug prescribing now includes pharmacists, nurse practitioners, nurse
midwives, physician assistants, and optometrists in a number of states of the USA. Physical
therapists are now billed to be licensed to prescribe drugs relevant to their specialist practice.
The primary organizations controlling the privilege of prescribing in the USA are the state
boards, under the powers delegated to them by the state legislatures. Several state boards have
attempted to reserve some measure of the primary responsibility for prescribing to physicians by
requiring that the ancillary professional work with or under a physician according to a specific
protocol. In California state, this protocol must include a certificate of their training, supervision,
and must specify referral requirements, limitations to the list of drugs that may be prescribed (ie,
a formulary), and a method of evaluation by the supervising physician. The protocol must be in
writing and must be periodically updated.

PRESCRIBING BY NON – PHYSICIANS IN THE VARIOUS STATES OF THE USA IS

GOVERNED BY CERTAIN RULES.

In almost all states, nurse practitioners (NPs) and physician assistants (PAs) may prescribe with
or without physician supervision. This very responsibility depends on the state. Also optometrists
may prescribe selected formulary drugs for ophthalmological indications. In three USA states,
Montana, New Mexico, and North Carolina, Pharmacists can initiate prescriptions. They may
practice with physicians in collaborative drug therapy management (CDTM) programs in 47
states-all except New York, Maine, Oklahoma, and Alabama. Pharmacists may prescribe
controlled substances under physician supervision in California, Massachusetts, Montana, New
Mexico, North Carolina, North Dakota, and Washington. With advanced training, New Mexico
grants prescribing authority to medical psychologists.
Prescriptions for substances with a high potential for abuse (Schedule II drugs) cannot be refilled
without a new prescription. However, multiple prescriptions for the same drug may be written
with instructions not to dispense before a certain date and up to a total of 90 days. Prescriptions
for Schedules III, IV, and V can be refilled if ordered, but there is a five-refill maximum, and in
no case may the prescription be refilled after 6 months from the date of writing. Schedule II drug
orders may not be transmitted over the telephone, and some states require a tamper-resistant
security prescription blank to reduce the chances for drug diversion. These restrictive prescribing
laws are intended to among other reasons limit the amount of drugs of abuse that are made
available to the public.

Schedule Potential for Other Comments

abuse
I High No accepted medical use, Lack of accepted safety as drug.
II High Current accepted medical use, Abuse may lead to psychological or
physical dependence.
III Less than I or II Current accepted medical use. Moderate or low potential for
physical dependence and high potential for psychological
dependence.
IV Less than I or Current accepted medical use. Limited potential for dependence
III
V Less than IV Current accepted medical use. Limited dependence profile.
Some states have recognized the underutilization of pain medications in the treatment of pain
associated with chronic and terminal conditions. California, for example, has enacted an
“intractable pain treatment” act that reduces the difficulty of renewing prescriptions for opioids.
Under the provisions of this act, upon receipt of a copy of the order from the prescriber, eg, by
fax, a pharmacist may write a prescription for a Schedule II substance for a terminally ill patient
under hospice care or living in a skilled nursing facility or in cases where the patient is expected
to live less than 6 months, provided that the prescriber countersigns the order (by fax); the word
“exemption” with regulatory code number is written on a typical prescription, thus providing
easier access of drugs for the terminally ill patient

SHEDULE OF CONTROLLED DRUGS (DRUGS OF ABUSE)

((Adopted from Katzung & Trevor, 13th Edition).

SHEDULE I
(All non-research use illegal under federal law.)
Flunitrazepam (Rohypnol)
Narcotics:
Heroin and many non-marketed synthetic narcotics
Hallucinogens:
LSD, MDA, STP, DMT, DET, mescaline, peyote, bufotenine, ibogaine, psilocybin,
phencyclidine (PCP; veterinary drug only)
Marijuana
Methaqualone

SHEDULE II
(No telephone prescriptions, no refills).
Opioids:
Opium
Opium alkaloids and derived phenanthrene alkaloids: Codeine, Morphine (Avinza, Kadian,
MSContin, Roxanol), Hydrocodone and Hydrocodone combinations (Zohydro ER, Hycodan,
Vicodin, Lortab), Hydromorphone (Dilaudid), Oxymorphone (Exalgo), Oxycodone
(dihydroxycodeinone, a component of Oxycontin, Percodan, Percocet, Roxicodone, Tylox).
Designated synthetic drugs: Meperidine (Demerol), Methadone, Levorphanol (Levo-Dromoran),
Fentanyl (Duragesic, Actiq), Fentora), alfentanil (Alfenta), sufentanil (Sufenta), remifentanil
(Ultiva), tapentadol (Nycynta).
Stimulants:
Coca leaves and Cocaine
Amphetamines: Amphetamine complex (Biphetamine), Amphetamine salts (Adderall),
Dextroamphetamine (Dexedrine), (Procentra), Lisdexamfetamine (Vyvanse), Methamphetamine
(Desoxyn), Methylphenidate (Ritalin, Concerta, Methylin, Daytrana, Medadate), Above in
mixtures with other controlled or uncontrolled drugs.
Cannabinoids:
Nabilone (Cesamet).
Depressants:
Amobarbital (Amytal) ,Pentobarbital (Nembutal) ,Secobarbital (Seconal).
SHEDULE III
(Prescription must be rewritten after 6 months or five refills.)
Opioids:
Buprenorphine (Buprenex, Subutex), Mixture of above Buprenorphine and Naloxone
(Suboxone)
The following opioids in combination with one or more active non-opioid ingredients, provided
the amount does not exceed that shown: Codeine and Dihydrocodeine: not to exceed 1800 mg/dL
or 90 mg/ tablet or other dosage unit.
Opium: 500 mg/dL or 25 mg/5 mL or other dosage unit (paregoric)
Stimulants:
Benzphetamine (Didrex) ,Phendimetrazine (Bontril)
Depressants:
Schedule II barbiturates in mixtures with noncontrolled drugs or in suppository dosage form
Barbiturates (butabarbital [Butisol], butalbital [Fiorinal]), Ketamine (Ketalar).
Cannabinoids:
Dronabinol (Marinol).
Anabolic Steroids: Fluoxymesterone (Androxy), Methyltestosterone (Android, Testred,
Methitest), Nandrolone decanoate (Deca- Durabolin) Non US, Nandrolone phenpropionate
(Durabolin) Non US, Oxandrolone (Oxandrin), Oxymetholone (Androl-50), Stanozolol
(Winstrol), Testolactone (Teslac), Testosterone and its esters.

SHEDULE IV
(Prescription must be rewritten after 6 months or five refills; differs from Schedule III in
penalties for illegal possession.)
Opioids:
Butorphanol (Stadol), Difenoxin 1 mg + atropine 25 mcg (Motofen) ,Pentazocine (Talwin).
Stimulants:
Armodafinil (Nuvigil),Diethylpropion (Tenuate) not in US ,Modafinil (Provigil) ,Phentermine
(Ionamin, Adipex-P).
Depressants:
Benzodiazepines: Alprazolam (Xanax), Chlordiazepoxide (Librium), Clonazepam (Klonopin),
Clorazepate (Tranxene), Diazepam (Valium), Estazolam (ProSom), Flurazepam (Dalmane),
Halazepam (Paxipam), Lorazepam (Ativan), Midazolam (Versed), Oxazepam (Serax), Prazepam
(Centrax), Quazepam (Doral), Temazepam (Restoril) Triazolam (Halcion) ,Chloral hydrate
(Somnote) ,Eszopiclone (Lunesta) ,Lacosamide (Vimpat) ,Meprobamate (Equanil, Miltown, etc)
Methobarbital (Mebaral),Methohexital (Brevital) ,Paraldehyde ,Phenobarbital ,Zaleplon (Sonata)
Zolpidem (Ambien).

SHEDULE V
(As any other nonopioid prescription drug) Codeine: 200 mg/100 mL Difenoxin preparations:
0.5 mg + 25 mcg atropine .Dihydrocodeine preparations: 10 mg/100 ML, Diphenoxylate (not
more than 2.5 mg and not less than 0.025 mg of atropine per dosage unit, as in
Lomotil),Ethylmorphine preparations: 100 mg/100 mL ,Opium preparations: 100 mg/100 mL
Pregabalin (Lyrica),Pyrovalerone (Centroton, Thymergix).

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737-4776.
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Dr Chukwu, Leo Clinton (2021).