Guidelines For Prescription Endorsement Of Hospital Or Institutional Drug Charts By Pharmacists

Administration/prescription chart review

Drug charts are available either electronically or as paper copies. For electronic prescribing systems, pharmacy approval/review of drug charts will be recorded by individual logins and specific processes dependent on the local system and electronic system.

Clinical pharmacists should initial and date all segment of drug charts where drugs have been prescribed when reviewing charts on the ward. This includes one-off or stat, PRN, syringe driver, and fluid prescriptions. The ‘clinical check’ estimate that all patient parameters are available to the pharmacist (i.e. drug history, medical notes, urea and electrolyte (U&E) levels, PODs, etc.).

If the clinical pharmacist clinically checks the drug chart in the dispensary, the following applies:

All drug entries should be clinically checked using the resources available in the dispensary (i.e. no access to patient’s notes, limited access to U&E levels); however, if required, the clinical pharmacist should obtain further information, e.g. by contacting the nurse or doctor looking after the patient.

All entries should be initial and dated by the pharmacist.

The ward clinical pharmacist should then treat the drug chart as for a new patient (i.e. check drug history, PODs, notes, and U&E levels, as appropriate.

Ideally, a drug history should be taken from the patient by the clinical pharmacist or pharmacy technician. This should be indicated by DHx, date and initial, and should be documented according to local policy.

Clinical pharmacists should check and write any identified drug allergies, sensitivities, intolerances, or ADRs, in addition to the reaction, in the appropriate section on the drug chart.

If the patient’s name, consultant, ward name, or hospital number is missing, illegible, or incorrect, this should be added or corrected by the clinical pharmacist. If appropriate and if it is missing from the chart, the patient’s weight and/or surface area should be added by the clinical pharmacist.

Drug name section

All drugs should be recommended by the clinical pharmacist with their non-proprietary approved names, unless they are combination products with no approved names.

Brand names should be added for medication where the brands are not interchangeable, such as ciclosporin, theophylline, mesalazine interferon, and lithium, for example. Brand names should also be added for modified release (M/R) Nifedipine, diltiazem, and verapamil. They are also desirable for oral contraceptives, hormone replacement therapy (HRT), multiple-ingredient skin products, and inhalers.

If M/R or enteric-coated (E/C) formulations are intended but not prescribed, drug names should be endorsed M/R or E/C. When liquid formulations are intended but not prescribed, drug names should be endorsed as liquid. The concentration should be specified. The dose in millilitres should be calculated and specified, if possible.

When a dose is prescribed that requires a combination of strengths, the usual combination should be clear up — e.g. digoxin 187.5 micrograms, 3 × 62.5micrograms, or 62.5 micrograms + 125-microgram tablets.

All changes agreed with the prescriber should be endorsed ‘confirmed with Dr [name]’, dated, and initialled. Do not use the abbreviation ‘pc’. Non-formulary, clinical trial, or ‘named-patient’ items should be recommended as such. Advice for insulins: The source of insulin should be specified (i.e. human, bovine, or porcine) along with the generic, brand, and the word insulin (e.g. Lantus R (glargine) insulin. The device used should also be endorsed (i.e. vial, 1.5mL or 3mL penfill, or disposable pen). Lastly, the mixture of insulin should be specified, if appropriate (e.g. 50/50).

Advice for inhalers: The strength of inhaler and the device (e.g. metered-dose inhaler (MDI), Easi-Breathe R, Accuhaler R, etc.) and whether used via a spacer should be specified.

Dose section

Doses should be endorsed as whole units when not so prescribed (e.g. 500mg not 0.5g).

Abbreviations should not be used: doses prescribed as ‘micrograms’ or ‘μg’ should be endorsed as ‘micrograms’, doses prescribed as ‘ng’ should be endorsed as ‘nanograms’, and similarly ‘IU’ or ‘U’ should be endorsed as ‘units’.

Dose times should be modified, as appropriate:

• To suit meal times — Calcichew R
• To avoid drug interactions related to absorption — e.g. ciprofloxacin and antacids
• Dose interval — antibiotics
• At night (nocte) — statins (not atorvastatin)
• In the morning (mane) — fluoxetine/paroxetine
• At 8am and 2pm to avoid nitrate tolerance — isosorbide mononitrate

Note: changes to dose time usually do not need to be assigned to the prescriber, dependent on local policy.

The dose and/or route should be clarified where unclear, e.g. ‘propranolol 1 tablet’ or (sublingual) ‘GTN PO’. These details should be confirmed with the patient or their notes, and do not usually have to be assigned to the prescriber, dependent on local policy. Endorse that the details were confirmed with patient/GP/notes etc.

Endorsement of drugs administered weekly (e.g. methotrexate and alendronic acid) must be clear, fix the day of the week the drug is usually taken. This can be made clear on the drug chart by crossing out administration tiles for all days except the prescribed day for clarity. As required, drugs specifying multiple routes are not determined, but if prescribed are endorsed with the appropriate dose for each route — e.g. prochlorperazine buccal/PO/IM 3mg/5mg/12.5mg, respectively.

As required, drugs should be endorsed with their maximum frequency or dose (e.g. analgesics) and/or instructions for use (e.g. anti-diarrhoeals). Prescriptions for IV drugs should be endorsed with injection or infusion rates or special requirements for boluses (e.g. furosemide). High-dependency areas could be exceptions from this requirement.

The rates of currently running drug-containing infusions should be checked, initialled, and dated in the pharmacy box. Eye drops and ointments should have left/right/both eye(s) specified.

Pharmacy annotation section

All drugs should be initial and dated by a clinical pharmacist, establishing the ‘clinical check’. Supply endorsements should then be made by the pharmacist:

• Stock items (S)
• One-stop supply (28 days)
• Controlled drugs (CDs)

Patient’s own drugs (PODs), including details of quantity and strength brought in and highlighting the date supplies were checked.

Symbols, such as triangle, circle, and slash, are used to distinguish entries from people’s initials:

Although self-administration should be inspired, such systems must be supported by specific protocols that have been agreed by your institution.

‘Non-formulary’, ‘clinical trial’, or ‘named patient’ should be written in full in the drug name box.

Prescriptions should be endorsed with the date that a supply is made.

Prescriptions should be endorsed with the quantity supplied each time a supply is made and the proper strength of the product supplied.

When a chart is rewritten, the ward clinical pharmacist should check each entry against the previous chart, initialing and dating each entry if it is correct. The clinical pharmacist should add the proper endorsing information with the date of the last supply (for information).