CHAP TER 3

PRESCRIPTIONS
LEARNING OBJECTIVES

Define prescription
> Know various parts of prescription
Understand drug related problems in prescriptions
Know about dispensing labeis and filling procedure

Prescription filling is one of the responsibilities of the pharmacists. Thus it is essential for
those
the pharmacists to know about various parts of a prescription, health care professionals
are eligible to write the prescriptions, and the procedure to label and fill the prescriptions.
Earliest
The concept of 'prescription goes dates back to the beginning of the history.Euphratus
prescriptions were found in 2700 B.C by Sumerians who lived between Tigris and
rivers. Early prescriptions were given for herb based medicines requiring mixing, steeping or
grinding. Modern prescription medicines are formulated using plant or chemical ingredients.
So long as there are medications, a writing system will exist to give directions for
preparation and usage.
Modern prescriptions are actually "extemporaneous prescriptions". In Latin (ex tempore
"Extemporaneous" means the prescription is written on the spot for a specificpatient with
specific ailment. This is distinguished from a non-extemporaneous prescription which is .
generic recipe for a general ailment. Modern prescriptions are evolved with the separating
role of the pharmacists from that of the physicians. Today the term "extemporaneous
prescriptions" is reserved for "compound prescriptions" which requires the pharmacist to mix
or "compound" the medication in the pharmacy for the specific needs of the patient. Prese
days, due to the availability of the readymade dosage forms by pharmaceutical companies
pharmacists' compounding activity has become obsolete. In modern days, prescription reten
to a list of medicines to be dispensed to the patient.

DEFINITION
In majorityof the countries, both medicine and pharmacy professions are regulatedbythe
t0
government and professional bodies. A prescription is a communication mechanism written
patient is also regulated and considered as alegal document. Aprescription is a

22
 CHAPTER 3 PRESCRIPTIONS 23

or computerized order from a prescriber directing the pharmacy to compound and or

dispense the medicines for patient's use. Regulations of a respective country may define
what a prescription should constitute, the contents and the format (including the size of the
paper) and how prescriptions should be handled and stored by the pharmacists. Some
countries allow the faxed or phone prescriptions containing the same information.
In some countries the preprinted prescription contains two signature lines: one line
indicates "dispense as written" printed underneath: the other line suggests "substitution
permitted". Some have a preprinted box "dispense as written" for the prescriber to check off
(but this is easily checked off by anyone with access to the prescription). In few countries,
the protocol for the prescriber is to handwrite one of the following phrases: "dispense as
written". "DAW", "brand necessary", "do not substitute", "no substitution'", "medically
necessary'", "do not interchange". In some countries different codes may be used. For
pediatric prescriptions, it is essential to write the age and weight of the child. Prescriptions
often have a "label" box. When written, the pharmacist is instructed to labelthe medications.
When not written, the patient only receives instructions for taking the medications and no
information about the prescription itself.

PARTS OF PRESCRIPTION
Currently two types of prescriptions are given to the patients. One is the conventional hand
written prescription and the other one is the computer generated prescription, which are
commonly given in corporate hospitals.
Often patients bring variety of prescriptions to the community pharmacies such as
medication name written overleaf of the bus tickets, small piece of paper, or on currency
notes. These are not considered as prescriptions. A valid prescription should possess the
following parts.
1. Superscription
2. Inscription
3. Subscription
4. Signa
1. Superscription: The superscription "Rx" means "take" in effect, "I want this patient
to have the following medications." This symbol had originated in medieval
manuscripts as an abbreviation of the Latin verb recipe, the imperative form of
recipere, "to take" or "take thus". Literally, the Latin word recipe means simply
"Take" and medieval prescriptions invariably began with the command to "take"
certain materials and compound them in specified ways. Today, when a medical
practitioner writes a prescription beginning with "Rx", he or she is completing the
command. Folk theories about the origin of the symbol Rnote its similarity to the Eye
of Horus,or to the ancient symbol for Zeus or Jupiter, (24), gods whose protection
may have been sought in medical contexts.
2. Inseription: The inscription is heart of the preseription. Inscription lists the
names and quantities of the medications to be used, Whenever there is doubt
 24 COMMUNITY PHARMACY PRACTICE

regarding the nanme of the medication or the dose mentioned, or duration of th.
treatment, the pharmacist should consult the doctor for clarification
corrections. This act not only ensures a good rapport with the doctor but ale
minimizes the dispensing errors.
3. Subscription: The subscription follows the inscription and is that part of the
prescription that gives directions to the pharmacist.
4. Signa: The signa, should not to be confused with the prescriber's signature.
This is the part of the prescription that gives the directions to the patient. This
portion is preceded by the abbreviation Sig" which is Prescriber Signature
Block. Finally, the prescriber signature block, located at the bottom of the
form, must contain a legible signature of the prescriber with date, as well as
the prescriber's full name, designation, address including the registration
number and contact phone number.

Prescription Number 0012 OP No: 0200908125

Mrs. GeethaGowda 45 yr
#692, MIG KHB Colony, Kalpavriksha Nagar, Mysore -7
Medications AM Noon
Evening PM
Ry
1 Tab. Amodep AT (30) 1
2. Tab. Diapride Forte (30) 1 0
3. Cap. Becosules (30) 1 0 0
4. Tab. Eliwel 12.5 mg (30) 0 0 1
Dispense as prescribed, Dr. K. Karthik Reddy M.D
Single filling only General Physician
Regd. No. KMC 1290

Date:

Fig. 3.1 Model Prescription

Who are Eligible to Write
Prescriptions?
Legally qualified and registered medical practitioners
give prescriptions to their patients for (MBBS,MD, MS) are only eligible
managing illnesses. In some countries, certified
nurse may also issue prescription with prior
the
clinician. In some countries, licensed certifiedpermission or the verbal instructions from u
clinical
physician assistants,
pharmacists are also eligible to write the prescriptions. However, optometrists and are not
medical students
eligible to give the prescriptions.
 CHAPTER 3 PRESCRIPTIONS 25

PRESCRIPTION HANDLING
Before dispensing the medications, it is essential to ensure that the prescription received is
honafide one from an authorized prescriber and the person brought the prescription is a
honafide patient. Prescriptions brought in a piece of paper or on empty spaces of cigarette
hoxes, or an empty medication strip, should not be dispensed. Once filled the prescription
chouldnot be refilled unless instructed by the prescriber.
Pharmacist should study the prescription carefully and make sure that the drug prescribed
is reasonable, that its amount or dosage is realistic in consideration with the patient's age,
and that the quantity of the medication is practical. For example, aprescription given for 20
Albrazolam tablets, warrants further inquiry. In the process of verification, if a discrepancy,
an ambiguity, or an incompatibility is observed in the given prescription, it is appropriate to
consult the prescriber. At the same time, patient should not be allowed to suspect that
that he
anvthing is amiss. Pharmacist should never filla prescription that is not understood or
or she feels is incorrect. Prescribers will appreciate if pharmacist consults them politely for
clarifying the doubts regarding the prescription given by them.
required to fill
If a prescription is found correct in all respects, an undivided attention is
while doing
the prescription. Most mistakes are made when the pharmacists are interrupted
process of filling a
so or are trying to accomplish more than one task at a time. During the
verified at least
prescription, the label on the carton box or the container should be
is taken from the
three times. Initially, the label should be read when the medication box
the container. And
shelf. Then it should be read again when the strips are removed from
before it is returned to the shelf.
finally, label on the container should be read
making
By following these three verification steps for each prescription filling, possibility of
should never substitute the
a prescription error is minimized. While dispensing, pharmacist
prescribed medicines without the permission of the doctor.

PRESCRIPTION LABELING
Prescription labeling is an important task in filling the prescriptions. Prescription labeling
length
helps the patient to take the medications in right quantity, at right time for the advised
of period. Improper labeling misguides the patient. The label should possess information
about the name of the patient, age, gender, name, dose of the medication, and its usage
instructions to the patient, details of the prescriber with the phone number and dispenser
details etc. Directions tothe patient regarding the medication use should be given in layman
language. Other information that may be attached on the prescription container
is "Shake Well before Use" or For External Use Only".
26 COMMUNITY PHARMACY PRACTICE

Mrs. Geetha Gowda 45 yr

692, MIG, KHB Colony, Kalpavriksha Nagar, Mysore -7
Tab. Amodep AT 30 Tabs
(Atenolol 50 mg + Amlodipine 5 mg)
Take one tablet after the breakfast. Take the tablet at same
time every day for best result
Prescribed by Dispensed by
Dr.Karthik Reddy T.Venu
Dispensing Pharmacist
Date: Sai Nihar medicals

Fig. 3.2 Dispensing Label

After dispensing the medications, the pharmacist should fix a seal
"DISPENSED" on the
prescription to prevent the misuse of the prescription for refilling unless
by the prescriber as number of refills permitted such as otherwise indicated
ONE or TW0. It is also important to
convey the message to patients to destroy the unused
medicines for safety reasons.
Filing of Prescriptions
In some countries pharmacists are
expected to file the
reasons. As a legal document, the regulations mandate thedispensed prescriptions for various
paper prescription in the pharmacy. Often the patients pharmacist to archive the original
with them. Some jurisdictions may entitle cannot take the original prescription
can be as long as ten years. In case the
patients to a copy. The retention period varies but
pharmacy is sold out or closed permanently for any
reasons, the pharmacist is expected tO return the
pharmacy. prescriptions to the patients or to nearby

CONVENTIONS TOo AvoID CONFUSIONS IN

INTERPRETING THE PRESCRIPTIONS
To avoid the ambiguity and
developed many conventions for misinterpretation of These
the prescriptions, prescribers have
1.
prescription-writing. include:
Careful use of decimal points to avoid
Avoiding unnecessary decimal ambiguity
5mL instead of 5.0 mL to avoid points:
A prescription will be written
possible misinterpretation of 5.0 as 50.
Always using zero prefix decimals: E.g., 0.5
misinterpretation of.5 as 5. instead of .5 to avo
Avoiding trailing zeros on decimals: E.g., 0.5 instead of ..50 to avoid
misinterpretation of .50 as 50.
2. "mL"is used instead of "cc" or
"cm" even common
avoid misinterpretation of 'c' as '0' or the though theymedical
are technically equivalentW
abbreviation for"with
 CHAPTER 3 PRESCRIPTIONS 27

(the Latin "cum"), which is written as a 'c' with a bar above the letter. Furthe, co
could be misinterpreted as "c.c.", which is an uncommonly used abbreviation for
"take with meals" (the Latin "cum cibo").
3. Directions written out in full in English.
4. Quantities given directly orimplied by the frequency and duration of the directions.
5. Where the directions are "as needed", the quantity should always be specified.
6. Where possible, usage directions should specify the time at which the medicine
should be taken such as 7 ann, 3 pm, 11 pmrather than simply writing the frequency
(three times a day) and cspecially with relationship to meals for orally consumed
medication.
7. Using pen with permanent ink while writing the prescription.
8. Avoiding unspecified prn or "as needed" instructions-instead, specific limits and
indicators are provided e.g., "every 3 hours prn pain".
9. For refills, the minimum duration between repeats and number of repeats should be
specified.
10. Providing the indication for all prescriptions even when obvious to the prescriber, so
that the pharmacist may identify possible errors.
11. Avoiding units such as "teaspoons" or "tablespoons".
12. Writing out numbers as words and numerals ("dispense #30 (thirty)")
13. The use of apothecary/avoirdupois units and symbols of measure pints (0),
ounces (3), drams (3), scruples (9), grains (gr), and minims (m) -- is discouraged to
avoid the confusion. For example, the abbreviation for a grain ("gr") can be confused
which looks almost
with the gram, abbreviated g, and the symbol for minims (M),
identical to an 'm', can be confused with micrograms or metres. Also, the symbols
numeral '3, and the
for ounce (3) and dram (3) can easily be confused with the
always be
symbol for pint (0) can be easily read as a '0". Metric equivalents should
used to avoid the errors.
abbreviation for
14. The use of the degree symbol (), which is commonly used as an
can be
hours (e.g., "q 2-40" for every 2-4 hours), should not be used, since it
confused with a 0'. Further, the use of the degree symbol for primary, secondary,
with
and tertiary (1°, 2°, and 3°) isdiscouraged, since the former could be confused
quantities (i.e., 10, 20 and 30, respectively).

PRESCRIPTION ABBREVIATIONS
Following abbreviations are commonly used in the prescriptions. It is important for the
pharmacists to know these abbreviations.
28 COMMUNITY PHARMACY PRACTICE

Abbreviation Latin
Meaning
aa ana of each
ad ad up to
a.c. ante cibum before meals
a.d. auris dextra right ear
ad lib ad libitum use as much as one desires; freely
admov. admove apply
agit agita stir/shake
alt. h. alternis horis every other hour
a.m.m ad manu medicae at doctors hand
a.m. ante meridiem morning, before noon
amp ampule
aqua water
a.u.
auris utraque both ears
b.d./b.i.d. bis in die twice daily
bol. bolus as a large single dose (usually intravenously)
B.S.A body surface areas
cf
with food
D.A.W.
dispense as written (i.e., no generic substitution)
d.t.d. dentur tales doses give of such doses
h.s. hora somni at bedtime
mane mane in the morning
oculus dexter right eye
p.c. post cibum after meals
p.m. post meridiem evening or afternoon
p.o. per os by mouth or orally
p.r. per rectum by rectum
PRN, pro re nata as needed
stat statim
wf immediately
f.i.d
with food (with meals)
Ter in die
g.i.d
Three times a day
Quarter in die Four times a day
KEY POINTS
Prescription is a written medication order given to a patient with
the patient. apurpose to u
Legally qualified and registered medical
prescriptions. practitioners are only eligible to write
A valid prescription should
possess superscription, subscription,
Signa. inscription