Appendix: Sample prescription form. The following sample prescription form gives examples of sections found in most hospital prescription forms.

Transcription

1 The hands-on guide to practical prescribing Oliver Jones, Nandan Gautam Copyright 2004 by Blackwell Publishing Appendix: Sample prescription form The following sample prescription form gives examples of sections found in most hospital prescription forms. 177

2 178 APPENDIX Generic General Hospital NHS Trust Prescription and Administration Record of admission of planned discharge TTOs written Chart Number 3 / 4 / TTOs received by pharmacy 1 of 1 / / 20 (Space for patient identification label) Name (Surname) NOTHER Unit No First Names ANN DOB 10/4/1945 Consultant Ward 6H Site Height cm Weight kg House Officer Bleep 1234 Allergies, Intolerances and other useful information ELASTOPLAST CONTACT DERMATITIS MIGRAINE INDUCED BY CAFFEINE Notes to prescribers Write legibly in black ink and use approved names for all drugs (Except where trade names are essential). Please avoid use of decimal point where possible. Any changes in drug therapy must be ordered by a new prescription, DO NOT alter existing instructions. This prescription sheet is valid for two weeks only. Antibiotics: Review antibiotics after 24 hours. The route should be changed to oral as soon as clinically possible. Please indicate a stop date when initiating oral treatment. Pre-medication, Once only drugs and Prophylactic Antibiotics Given Initials 0800 TEMAZEPAM 10 mg 0 on induction CEFUROXIME METRONIDAZOLE induction 1.5 g 500 mg 0800 BRUFEN 800 mg O

3 SAMPLE PRESCRIPTION FORM 179 Oxygen Therapy Oxygen Low concentration (Venturi Connector) Concentration 24/28/31% Target saturation (Delete*) PRN* or Continuous* Oxygen Low concentration (Nasal cannulae) Rate 1 4 litres/min (Delete*) PRN* or Continuous* Target saturation Oxygen Medium to High concentration Rate 4 15 litres/min (Delete*) PRN* Target saturation 95% When required medication Infusion Therapy Each prescription is once only. A new prescription must be written if the infusion is repeated Infusion solution Additives and dose Volume Rate Doctors's signature started and stopped Added by and given by N/SALINE N/SALINE + 20mmol KCl IL 6 IL AN AN GELOFUSINE 500mls STAT

4 180 APPENDIX Regular Medication Notes to nursing staff When a drug is NOT administered, record the appropriate number and your initials, in the relevant box and if appropriate document in the nursing records: Patient away from ward Patient could not take drug or supplement (e.g. Nil by mouth, Vomiting) Patient refused drug or supplement or supplement not available 5. Nursing decision (document in nursing records) 6. On instructions of doctor (document in nursing records) 7. Patient is self-administering medication or supplement 8. Not all drug or supplement taken Warfarin at 6pm Target INR/Indication INR Sig. PARACETAMOL 5/4 1g qds O BRUFEN 400mg tds O with food X CEFUROXIME 1.5g tds METRONIDAZOLE 500mg tds

5 SAMPLE PRESCRIPTION FORM 181 Blood/Blood Components/Blood Products Type of Blood/ component/ product PACKED RED CELLS CMV Neg Yes/No Irradiated Yes/No Volume Rate Doctor's N N 1 unit 4 Unit/Batch No. started & stopped by and given by FFP 1 bag 20 min PCA and Epidural Prescriptions Syringe 1 Syringe 2 Syringe 3 Patient Controlled Analgesia 1 & amount added MORPHINE 50mg 2 & amount added started started Diluent & syringe volume Loading dose N/SALINE 50 mls NONE stopped Background infusion PCA Bolus dose Lockout time stopped NONE 1 mg 5 min Stopped by Follow PCA guidelines, DO NOT GE OTHER SYSTEMIC OPIOIDS WHILST ON PCA Naloxone 400 mg If respiratory rate 8 per minute, or patient unrousable Pharm. Syringe 1 Syringe 2 Syringe 3 Epidural Analgesia If epidural opioids administered, Do not give systemic opioids 1 & Concentration 2 & Concentration started started Diluent & syringe volume Infusion rate stopped stopped Naloxone If respiratory rate 8 per minute, or patient unrousable Ephedrine If required for severe or persistent hypertension Pharm.