Medical prescription

A prescription, often abbreviated ℞ or Rx, is a health care program implemented by a physician or other qualified health care practitioner in the form of instructions that govern the plan of care for an individual patient.[1] The term often refers to a health care provider's written authorization for a patient to purchase a prescription drug from a pharmacist.

The prescription symbol, ℞, printed on the blister pack of a prescription drug manufactured in the Philippines

Format and definition
℞
Medical prescription
In UnicodeU+211E ℞ PRESCRIPTION TAKE (HTML ℞)
Related
See alsoU+2695 ⚕ STAFF OF AESCULAPIUS
The symbol "℞", sometimes transliterated as "Rx" or "Rx", is recorded in 16th century manuscripts as an abbreviation of the late Latin instruction recipe, meaning 'take thou'.[2][lower-alpha 1] Originally abbreviated Rc, the later convention of using a slash to indicate abbreviation resulted in an R with as a straight stroke through its right "leg".[2][lower-alpha 2][lower-alpha 3] Medieval prescriptions invariably began with the command to "take" certain materials and compound them in specified ways.[7]

In the United States, the format of a prescription falls into seven parts. However, with modern prescribing habits, some parts are no longer applicable or included on an everyday basis.

Definition: For a prescription to be accepted as a legal medical prescription, it needs to be filed by a qualified dentist, herbalist, advanced practice nurse, pharmacist, physician, psychiatrist, veterinarian etc., for whom the medication prescribed is within their scope of practice to prescribe such treatments. This is regardless of whether the prescription includes controlled substances or over-the-counter treatments.

Prescriptions may be entered into an electronic medical record system and transmitted electronically to a pharmacy. Alternatively, a prescription may be handwritten on preprinted prescription forms that have been assembled into pads, or printed onto similar forms using a computer printer or even on plain paper according to the circumstance. In some cases, a prescription may be transmitted from the physician to the pharmacist orally by telephone; this practice may increase the risk of medical error. The content of a prescription includes the name and address of the prescribing provider and any other legal requirement such as a registration number (e.g. DEA Number in the United States). Unique for each prescription is the name of the patient. In the United Kingdom and Ireland, the patient's name and address must also be recorded. Each prescription is dated and some jurisdictions may place a time limit on the prescription.[8] In the past, prescriptions contained instructions for the pharmacist to use for compounding the pharmaceutical product but most prescriptions now specify pharmaceutical products that were manufactured and require little or no preparation by the pharmacist. Prescriptions also contain directions for the patient to follow when taking the drug. These directions are printed on the label of the pharmaceutical product.

The word "prescription", from "pre-" ("before") and "script" ("writing, written"), refers to the fact that the prescription is an order that must be written down before a compound drug can be prepared. Those within the industry will often call prescriptions simply "scripts".

In certain states, medical marijuana legislation has been drafted calling for a health care professional's written or oral "recommendation", in the belief that a written one would be legally distinguishable from a prescription. Since written advice to a patient is what a prescription is, the belief that such a recommendation is not a prescription is mistaken. Jurisdictions may adopt a statutory definition of "prescription" that applies as a term of art only to the operation of that statute (see below about prescriptions that may legally be filled with prescription-only items), but the general legal definition of the word is this broad one.

Contents

Every prescription contains who prescribed the prescription, who the prescription is valid for, and what is prescribed. Some jurisdictions, drug types or patient groups require additional information as explained below.

In some countries, drug companies use direct-to-prescriber advertising in an effort to convince prescribers to dispense as written with brand-name products rather than generic drugs.

Drug equivalence and non-substitution

Many brand name drugs have cheaper generic drug substitutes that are therapeutically and biochemically equivalent. Prescriptions will also contain instructions on whether the prescriber will allow the pharmacist to substitute a generic version of the drug. This instruction is communicated in a number of ways. In some jurisdictions, the preprinted prescription contains two signature lines: one line has "dispense as written" printed underneath; the other line has "substitution permitted" underneath. 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 other jurisdictions, the protocol is for the prescriber to handwrite one of the following phrases: "dispense as written", "DAW", "brand necessary", "do not substitute", "no substitution", "medically necessary", "do not interchange".[9] In Britain's National Health Service, doctors are reminded that money spent on branded rather than generic drugs is consequently not available for more deserving cases.[10]

Prescriptions for children

In some jurisdictions, it may be a legal requirement to include the age of child on the prescription.[11] For pediatric prescriptions some advise the inclusion of 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.

Label and instructions

Prescriptions in the USA often have a "label" box.[12] When checked, the pharmacist is instructed 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 prescribers further inform the patient and pharmacist by providing the indication for the medication; i.e. what is being treated. 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.

Writing prescriptions

National or local (i.e. state or provincial) legislation governs who can write a prescription. In the United States, physicians (either M.D., D.O. or D.P.M.[13]) have the broadest prescriptive authority. All 50 states and the District of Columbia allow licensed certified Physician Assistants (PAs) prescription authority (with some states, limitations exist to controlled substances). All 50 states and the District of Columbia, Puerto Rico and Guam allow registered certified nurse practitioners and other advanced practice registered nurses (such as certified nurse-midwives) prescription power (with some states including limitations to controlled substances).[14][15] Many other healthcare professions also have prescriptive authority related to their area of practice. Veterinarians and dentists have prescribing power in all 50 states and the District of Columbia. Clinical pharmacists are allowed to prescribe in some states through the use of a drug formulary or collaboration agreements. Florida pharmacists can write prescriptions for a limited set of drugs.[16] In all states, optometrists prescribe medications to treat certain eye diseases, and also issue spectacle and contact lens prescriptions for corrective eyewear.[17] Several states have passed RxP legislation, allowing clinical psychologists (PhDs or PsyDs) who are registered as medical psychologists and have also undergone specialized training in script-writing to prescribe drugs to treat emotional and mental disorders. Chiropractors may have the ability to write a prescription, depending on scope of practice laws in a jurisdiction.

In August 2013, legislative changes in the UK allowed physiotherapists and podiatrists to have independent prescribing rights for licensed medicines that are used to treat conditions within their own area of expertise and competence.[18]

Legibility of handwritten prescriptions

Doctors' handwriting is a reference to the stereotypically illegible handwriting of some medical practitioners, which sometimes causes mistreatment. In the US, illegible handwriting has been indirectly responsible for at least 7,000 deaths annually.[19][20][21][22]

There are several theories about the causes of this phenomenon. Some sources say the extreme amount of writing doctors employ during training and at work leads to bad handwriting,[23] whereas others claim that doctors neglect proper handwriting due to medical documents being intended to be read solely by medical professionals, not patients.[24] Others simply classify the handwriting of doctors as a handwriting style.[25][26] The issue may also have a historical origin, as physicians from Europe-influenced schools have historically used Latin words and abbreviations to convey prescriptions; many of the abbreviations are still widely used in the modern day and could be a source of confusion.

Some jurisdictions, such as Florida, have legislatively required prescriptions to be legible,[27] and some organizations have advocated the elimination of handwritten prescriptions altogether.[28] There have been numerous devices designed to electronically read the handwriting of doctors, including electronic character recognition,[29] keyword spotters,[30] and "postprocessing approaches,"[31] though the gradual shift to electronic health records and electronic prescriptions may alleviate the need for handwritten prescriptions altogether.[32] In Britain's NHS, remaining paper prescriptions are almost invariably computer printed and electronic (rather than paper) communication between surgery and pharmacy is increasingly the norm.<[33]

Conventions for avoiding ambiguity

Over the years, prescribers have developed many conventions for prescription-writing, with the goal of avoiding ambiguities or misinterpretation.[34][35][36] These include:

  • Careful use of decimal points to avoid ambiguity:
    • Avoiding unnecessary decimal points: a prescription will be written as 5 mL instead of 5.0 mL to avoid possible misinterpretation of 5.0 as 50.
    • Always using zero prefix decimals: e.g. 0.5 instead of .5 to avoid misinterpretation of .5 as 5.
    • Avoiding trailing zeros on decimals: e.g. 0.5 instead of .50 or 0.50 to avoid misinterpretation of .50 as 50.
  • "mL" is used instead of "cc" or "cm3" even though they are technically equivalent to avoid misinterpretation of 'c' as '0' or the common medical abbreviation for "with" (the Latin "cum"), which is written as a 'c' with a bar above the letter. Further, cc could be misinterpreted as "c.c.", which is a rarely used abbreviation for "take with meals" (the Latin "cum cibo").
  • Directions written out in full in English (although some common Latin abbreviations are listed below).
  • Quantities given directly or implied by the frequency and duration of the directions.
  • Where the directions are "as needed", the quantity should always be specified.
  • Where possible, usage directions should specify times (7 am, 3 pm, 11 pm) rather than simply frequency (three times a day) and especially relationship to meals for orally consumed medication.
  • The use of permanent ink.
  • Avoiding units such as "teaspoons" or "tablespoons".
  • Writing out numbers as words and numerals ("dispense #30 (thirty)") as in a bank draft or cheque.
  • The use of apothecary/avoirdupois units and symbols of measure – pints (O), ounces (℥), drams (ℨ), scruples (℈), grains (gr), and minims (♏) – is discouraged given the potential for confusion. For example, the abbreviation for a grain ("gr") can be confused with the gram, abbreviated g, and the symbol for minims (♏), which looks almost identical to an 'm', can be confused with micrograms or metres. Also, the symbols for ounce (℥) and dram (ℨ) can easily be confused with the numeral '3', and the symbol for pint (O) can be easily read as a '0'. Given the potential for errors, metric equivalents should always be used.
  • The degree symbol (°), which is commonly used as an abbreviation for hours (e.g., "q 2-4°" for every 2–4 hours), should not be used, since it can be confused with a '0' (zero). Further, the use of the degree symbol for primary, secondary, and tertiary (1°, 2°, and 3°) is discouraged, since the former could be confused with quantities (i.e. 10, 20 and 30, respectively).
  • Micrograms are abbreviated mcg rather than µg (which, if handwritten, could easily be mistaken for mg (milligrams)). Even so, pharmacists must be on the alert for inadvertent over- or under-prescribing through a momentary lapse of concentration.

Abbreviations
See also: List of abbreviations used in medical prescriptions

Many abbreviations are derived from Latin phrases. Hospital pharmacies have more abbreviations, some specific to the hospital. Different jurisdictions follow different conventions on what is abbreviated or not. Prescriptions that do not follow area conventions may be flagged as possible forgeries.

Some abbreviations that are ambiguous, or that in their written form might be confused with something else, are not recommended and should be avoided. These are included in a separate list in Appendix 1. However, all abbreviations carry an increased risk for confusion and misinterpretation and should be used cautiously.

Non-prescription drug prescriptions

Prescriptions are also used for things that are not strictly regulated as a prescription drug. Prescribers will often give non-prescription drugs out as prescriptions because drug benefit plans may reimburse the patient only if the over-the-counter medication is taken under the direction of a medical practitioner. Conversely, if a medication is available over-the-counter, prescribers may ask patients if they want it as a prescription or purchase it themselves. Pharmacists may or may not be able to price the medication competitively with over-the-counter equivalents. If the patient wants the medication not under prescription, the prescriber is usually careful to give the medication name to the patient on a blank piece of paper to avoid any confusion with a prescription. This is applied to non-medications as well. For example, crutches and registered massage therapy may be reimbursed under some health plans, but only if given out by a prescriber as a prescription. Some software now requires a prescription.[37]

Prescribers will often use blank prescriptions as general letterhead. Legislation may define certain equipment as "prescription devices".[38] Such prescription devices can only be used under the supervision of authorized personnel and such authorization is typically documented using a prescription. Examples of prescription devices include dental cement (for affixing braces to tooth surfaces), various prostheses, gut sutures, sickle cell tests, cervical cap and ultrasound monitor.

In some jurisdictions, hypodermic syringes are in a special class of their own, regulated as illicit drug use accessories[39] separate from regular medical legislation. Such legislation will often specify a prescription as the means by which one may legally possess syringes.

Prescription may also be used as a short form for prescription drugs to distinguish from over-the-counter drugs. In reference to the entire system of controlling drug distribution (as opposed to illicit drugs), "prescription" is often used as a metaphor for healthy directions from a prescribing medical practitioner. A green prescription is direction from a medical practitioner to a patient for exercise and healthy diet.

History

The idea of prescriptions dates back to the beginning of history. So long as there were medications and a writing system to capture directions for preparation and usage, there were prescriptions.[40]

Modern prescriptions are actually extemporaneous prescriptions (from the Latin ex tempore, "at/from the time"),[41] meaning that the prescription is written on the spot for a specific patient with a specific ailment. This is distinguished from a non-extemporaneous prescription that is a generic recipe for a general ailment. Modern prescriptions evolved with the separation of the role of the pharmacists from that of the physician.[42] Today the term extemporaneous prescriptions is reserved for compound prescriptions that requires the pharmacist to mix or compound the medication in the pharmacy for the specific needs of the patient.

Predating modern legal definitions of a prescription, a prescription traditionally is composed of four parts: a superscription, inscription, subscription, and signature.[43]

The superscription section contains the date of the prescription and patient information (name, address, age, etc.). The symbol "℞" separates the superscription from the inscriptions sections. In this arrangement of the prescription, the "℞" is a symbol for recipe or literally the imperative "take!" This is an exhortation to the pharmacist by the medical practitioner, "I want the patient to have the following medication"[44] – in other words, "take the following components and compound this medication for the patient."

The inscription section defines what is the medication. The inscription section is further composed of one or more of:[45]

  • a basis or chief ingredient intended to cure (curare)
  • an adjuvant to assist its action and make it cure quickly (cito)
  • a corrective to prevent or lessen any undesirable effect (tuto)
  • a vehicle or excipient to make it suitable for administration and pleasant to the patient (jucunde)

The subscription section contains dispensing directions to the pharmacist. This may be compounding instructions or quantities.

The signature section contains directions to the patient[46] and is often abbreviated "Sig."[47] or "Signa."[48] It also obviously contains the signature of the prescribing medical practitioner though the word signature has two distinct meanings here and the abbreviations are sometimes used to avoid confusion.

Thus sample prescriptions in modern textbooks are often presented as:

℞:  medication
Disp.:  dispensing instructions
Sig.: patient instructions

Use of technology
Further information: Electronic prescribing and electronic health record

As a prescription is nothing more than information among a prescriber, pharmacist and patient, information technology can be applied to it. Existing information technology is adequate to print out prescriptions. Hospital information systems in some hospitals do away with prescriptions within the hospital. There are proposals to securely transmit the prescription from the prescriber to the pharmacist using smartcard or the internet.[49] In the UK a project called the Electronic Transfer of Prescriptions (ETP) within the National Programme for IT (NPfIT) is currently piloting such a scheme between prescribers and pharmacies.

Within computerized pharmacies, the information on paper prescriptions is recorded into a database. Afterwards, the paper prescription is archived for storage and legal reasons.

A pharmacy chain is often linked together through corporate headquarters with computer networking. A person who has a prescription filled at one branch can get a refill of that prescription at any other store in the chain, as well as have their information available for new prescriptions at any branch.

Some online pharmacies also offer services to customers over the internet, allowing users to specify the store that they will pick up the medicine from.

Many pharmacies now offer services to ship prescription refills right to the patient's home. They also offer mail service where you can mail in a new, original prescription and a signed document, and they will ship the filled prescription back to you.

Pharmacy information systems are a potential source of valuable information for pharmaceutical companies as it contains information about the prescriber's prescribing habits. Prescription data mining of such data is a developing, specialized field.[50]

Many prescribers lack the digitized information systems that reduce prescribing errors.[51] To reduce these errors, some investigators have developed modified prescription forms that prompt the prescriber to provide all the desired elements of a good prescription. The modified forms also contain predefined choices such as common quantities, units and frequencies that the prescriber may circle rather than write out. Such forms are thought to reduce errors, especially omission and handwriting errors and are actively under evaluation.[52]

See also

References

Footnotes
  1. second person singular imperative form of recipere meaning "receive" or "take", thus: "take thou".[3]
  2. Compare with Pound sign#Origin. Transliteration as Rx is ubiquitous but erroneous, it is not an x.
  3. Folk theories about the origin of the symbol '℞' note its similarity to the Eye of Horus,[4][5] or to the ancient symbol for Zeus or Jupiter, (♃), gods whose protection may have been sought in medical contexts.[6] No objective evidence has been produced for these theories.

Citations
  1. Belknap, SM; Moore, H.; Lanzotti, SA; Yarnold, PR; Getz, M.; Deitrick, DL; Peterson, A.; Akeson, J.; Maurer, T.; Soltysik, RC; Storm, GA; Brooks, I. (2008). "Application of Software Design Principles and Debugging Methods to an Analgesia Prescription Reduces Risk of Severe Injury from Medical Use of Opioids". Clinical Pharmacology & Therapeutics. 84 (3): 385–392. doi:10.1038/clpt.2008.24. PMID 18388884.
  2. "Definition of Rx". Merriam Webster. 19 December 2019. a 16th-century symbol, the letter R with a line through its slanted leg-the line signaling that the "R" is functioning as an abbreviation.
  3. "Latin verbs: recipere". cactus2000.de. Retrieved 2019-12-19.
  4. Eye of Horus, Eye of Ra (Udjat, Wedjat) Archived October 12, 2007, at the Wayback Machine
  5. "First recorded incidence of the pharmaceutical sign 'Rx'". Egyptphoto.ncf.ca. Retrieved 2012-02-13.
  6. Amy Beth Dukoff. "Did You Know Where Rx Came From?". Endomail.com. Archived from the original on 2013-10-03. Retrieved 2014-01-02.
  7. Oxford English Dictionary, articles on the letter "R" (sense 14b) and the word "recipe."
  8. "Guide to Good Prescribing - A Practical Manual: Part 3: Treating your patients: Chapter 9. STEP 4: Write a prescription". apps.who.int. Retrieved 26 March 2018.
  9. "State Laws or Statutes Governing Generic Substitution by Pharmacists". : Epilepsy.com/Professionals. 2007-04-25. Retrieved 2014-01-02.
  10. Medicines Optimisation Team (April 2019). Generic Prescribing Guidelines (PDF) (Report). Greater Manchester Health and Care Commissioning. Retrieved 26 May 2020.
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  12. Davis, T (August 30, 2005). "Prescription Writing and the PDR". Comprehensive Care Clinic. Retrieved 2014-01-02.
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  21. Caplan, Jeremy (2007-01-15). "Cause of Death: Sloppy Doctors". Time. ISSN 0040-781X. Retrieved 2019-05-06.
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  25. "Legibility of doctors' handwriting is as good (or bad) as everyone else's". CiteSeerX 10.1.1.657.9146. Cite journal requires |journal= (help)
  26. Harralson, Heidi H. (2014-09-25). Developments in Handwriting and Signature Identification in the Digital Age. Routledge. ISBN 978-1-317-52288-1.
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  28. "Eliminate Handwritten Prescriptions Within 3 Years". Institute for Safe Medication Practices. 1999-12-07. Retrieved 2010-01-22.
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  31. Chen, Qi; Gong, Tianxia; Li, Linlin; Tan, Chew Lim; Pang, Boon Chuan (November 2010). "A Medical Knowledge Based Postprocessing Approach for Doctor's Handwriting Recognition". 2010 12th International Conference on Frontiers in Handwriting Recognition: 45–50. doi:10.1109/ICFHR.2010.121. ISBN 978-1-4244-8353-2.
  32. Robaina Bordón, J. M.; Morales Castellano, E.; López Rodríguez, J. F.; Sosa Henríquez, M. (December 2014). "La letra de médico". Revista de Osteoporosis y Metabolismo Mineral. 6 (4): 122–126. doi:10.4321/S1889-836X2014000400008. ISSN 1889-836X.
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  38. "CFR – Code of Federal Regulations Title 21". U.S. Food and Drug Administration (FDA). 2009-04-01. Retrieved 2014-01-02.
  39. "(720 ILCS 635/) Hypodermic Syringes and Needles Act". Illinois Compiled Statutes.
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  42. Anderson, Stuart (26 March 2018). "Making Medicines: A Brief History of Pharmacy and Pharmaceuticals". Pharmaceutical Press. Retrieved 26 March 2018 – via Google Books.
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  47. Archived August 26, 2003, at the Wayback Machine
  48. Ansel, H. Pharmaceutical Calculations. 13th edition, Philadelphia. Lippincott, Williams, and Wilkins. 2010. p59-60.
  49. "IEEE Computer Society Conference Publishing Services".
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Further reading
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