prescription writing-basic guide
Prescription should be properly written and before we go over bout it. It is worth briefly discussing two common sources of prescription errors we as clinicians we make.
- First, if you are handwriting your prescription, make sure that it is legible. Illegible prescriptions are a source of frustration for patients, pharmacists, and other medical providers. It can increase the risk of medication errors. Some times you may be busy but it’s always better to spend a few extra seconds writing out a legible prescription than risking your patient’s health.
- Second, be cautious when using abbreviations. While we commonly use abbreviations in medicine. You should keep in mind that the risk of a medication error is increased when abbreviations are ambiguous or used incorrectly. So if you choose to use abbreviations in your prescriptions, be sure to only use well-known ones. Some commonly used medical abbreviations can be found here. If you are unsure whether or not you should use an abbreviation, just write out your directions completely.
Now lets discuss how to properly write prescription. Every prescription consists of seven parts:
- The prescriber’s information.
- The patient’s information.
- The recipe (the medication, or Rx).
- The signatura (the patient instructions or Sig).
- The dispensing instructions (how much medication to be dispensed to the patient or Disp).
- The number of refills (or Rf) and
- The prescriber’s signature (including his or her National Provider Identifier).
Below, we will review each of these sections in more detail.
How to write a prescription in 7 steps:
This information is usually found at the top of the prescription. It generally consists of the prescribing clinician’s name, office address, and contact information (usually the office’s telephone number).
Below the prescriber’s information is the patient’s information. This section will include the patient’s full name, age, and date of birth. Sometimes the patient’s home address will be found here, as well. Date of the prescription should be specified when was written.
The recipe should include the medication being prescribed, its dose, and its dosage form. For example, if you are prescribing 400 milligram (mg) tablets of ibuprofen, you would write “ibuprofen 400 mg tablets” or “ibuprofen 400 mg tabs.”
After the recipe comes the signatura. This provides the patient with instructions on how to take the medication you are prescribing. It should include information on how much medication to take, how to take it, and how often to take it.
For example, if you would like your patient to take one 400 mg tablet of ibuprofen every eight hours, you would write: “Take 1 tablet by mouth every eight hours” or, using abbreviations, “1 tab PO q8h.”
Pro re nata (PRN) or for as needed prescriptions;
You should indicate that the prescription is PRN and describe the conditions under which your patient can take the prescribed medication. Writing your prescription as a PRN order essentially gives the patient the option to take the medication when he or she needs it.
Let’s say that you would like your patient to take one 400 mg tablet of ibuprofen every eight hours when he or she has a headache. In that case, your instructions would read: “Take 1 tablet by mouth every eight hours as needed for a headache” or “1 tab PO q8h prn headache.”
Dispensing Instructions (Disp)
Next in the line is the dispensing instructions. This let’s the pharmacist to know how much medication you would like your patient to receive. You should include the amount of medication you would like to be dispensed and the form it should be released in. You should also make sure to write out any numbers you use here to minimize the risk of a medication error. For our ibuprofen example, if you would like your patient to receive a one week supply (or 21 tablets) of the medication, you would write “21 (twenty-eight) tablets” or “21 (twenty-one) tabs.”
Number of Refills (Rf)
After the dispensing instructions. Specify how many times you would like your patient to be able to use this prescription to refill his or her medication. Be sure to again write out any numbers you use. If you do not want to prescribe any refills, write “zero refills.” For our hypothetical ibuprofen example, if you are prescribing one refill, you would write “1 (one) refill.”
At the bottom of the prescription, you should sign your name. Often times, the prescriber’s registration number as per regulating body will be included in this section. For controlled substances, the prescriber’s Drug Enforcement Agency Number will also be included in some countries .
Example of prescription would look like this: