Prescribing on an FP-10

Just wanted to clarify one thing. You write the dose as the strength of tablet rather than the total intended dose per frequency, right?

For example, prescribing Pen V at 500mg QDS. The BNF lists 250mg strength tablets, so the patient has to take two tablets of 250mg Pen V four times a day.

You would write this as:
"PHENOXYMETHYLPENICILLIN tablets 250mg - take TWO tablets FOUR TIMES a day"

So the actual dose prescribed at that frequency (ie, 500mg) doesn't need to appear anywhere on the FP10?

Cheers :redface:

(edited 9 years ago)

Reply 1

thegodofgod

Original post by Tech

Yup, that's right :smile:

Reply 2

nexttime

I've seen it done both ways. Its the pharmacist's duty to make sure the patient is clear on how to take medication (though I'm sure they will appreciate clear instructions from the doctor).

Important thing to remember versus normal prescriptions is to write how many days supply/tablets you want to be given out.

Remember that it's an outpatient prescription so cannot be signed by fy1s (Though I have written many).

Reply 3

Spencer Wells

The pharmacist can write whatever they like on the label, so you can just prescribe the total dose (in your example 500mg QDS) and the pharmacist can decide how to make that up - it may be that they have a stock of 500mg tabs/caps (and they can substitute tablets for capsules if they want) so you don't need to be that precise. The exception is with controlled drugs.

Remember that you cannot prescribe on an FP10 (or any other outpatient prescription) until you have full GMC registration (i.e. have passed FY1)

Reply 4

thegodofgod

Original post by Spencer Wells

Interestingly, although it is possible to substitute tabs for caps if the pharmacist wishes to do so, the NHS only pays for what the prescription says. So if you do decide to make the substitution from tabs to caps for whatever reason, the pharmacy might find itself making a loss, as caps tend to be more expensive (on the whole) than tabs.

Reply 5

Tech

Thanks for the help guys.

Reply 6

Friar Chris

Original post by Tech

As posters have said above, but to clarify:

Your job is to decide what to prescribe and to clearly and safely then prescribe it. To do so, it's both easier and more appropriate to prescribe the dosage and the frequency; there can be no confusion about this.

Your job is not to know or research what compositions of that medicine are available and then to try and write a prescription detailing what size of tablet should be used and how many should be taken at once and what colour they should be and how many stripes should be on the capsule and...

My personal feeling, and what I've been taught, is that you prescribe the dose. Why so? Well, for a few reasons:

•

If you're specifying the precise preparation then you're making life difficult for everyone involved. You might want to prescribe 500mg QDS and look it up in the BNF and then write 'two 250mg tablets QDS' on the script, but the pharmacy may well only stock 500mg tablets (or maybe capsules, oh my) and now you've made your prescription so specific as to technically be a problem.

•

You're more likely to make a mistake. Trying to prescribe 'two 250mg tablets QDS' could easily be accidentally written as '250mg tablet QDS', giving the patient only half a dose. And when tired on a long day, there's more scope for mixing frequencies and doses up if you're trying to specify the composition of tablets as well as the actual dosing and frequency. It also makes any potential handwriting problems twice as bad for the same reason; you may well have written '2 250mg tablets QDS' but because of the way it looks it could be misread as '250mg tablets QDS'... Whereas '500mg QDS PO' has far less scope for this problem as the total dosage is clearly stated.

•

You want to give x dose by y method. If the method's PO, it doesn't matter* whether that's in tablets, capsules, caplets, solution, syrup, suspension, dispersible tablet... It's PO, so long as it's the correct form and dose of the drug being given. Different pharmacies may use different things for the same drug; who really cares whether your paracetamol is in 500mg tablets or 500mg capsules? Indeed in some patients it may be better to leave it at PO - little old Doris Jones has had problems swallowing since her stroke and she may prefer her long-term prophylactic trimethoprim in a nice syrup instead of hard tablets. Though almost certainly in a GP setting you'd see the patient and ask for a specific formulation if they had a specific need, it helps not to constrain something unnecessarily.

Finally, from a medico-legal aspect, if you did make a mistake writing out precisely what composition and preparation you wanted, specifying how many of what strange size of tablet, then it's on your head. If you want a patient to have 100mg BD of nitrofurantoin PO for 3 days, then write Nitrofurantoin 100mg BD PO for 3 days. If the pharmacist dispenses anything other than that, it's not your fault. That is a clear instruction on the prescription and you cannot be held at fault for being unclear or making a mistake about precisely how often and in how many little tablets and what type of pill. If, on the other hand, you tried to write up 50mg QDS but accidentally defaulted to 'two 50mg tablets' (as might be dispensed by the pharmacist for a 100mg BD prescription) and then also QDS because you've been working all day and you're on autopilot, a double dose has now been prescribed and its your fault. The pharmacist may hopefully pick it up and not dispense it (especially with more dangerous drugs than nitrofurantoin), but it's not their responsibility, and the culpability is on you for writing an incorrect prescription, not helped by the fact that you've made the prescription twice as complicated as necessary causing the slight error. You are not an expert on the myriad types of preparation in the BNF available; there's not really a leg to stand on if you try to do the pharmacist's job for them.

With regards to explaining to patients - especially if you're using a computerised GP system which unlike an FP-10 usually shows what preparations are stocked and used in the local area and so generates that for you - it's fine to clarify what they're likely or (in the example of that electronic prescription) precisely what they're getting. Patient education is good, but there's no need to be dictating what size and colour of tablet on the prescription itself, especially in the context of an FP-10 where you don't have that electronic facility.

*There are a few exceptions, most notably psychiatric and anti-epileptic medications, which though are technically identical through various brands and tablet vs caplet, you just don't want to mess with if a patient has always received the same type. If Tegretol® has always controlled your patient's seizures, it's absolutely appropriate to specify that brand on the script as opposed to 'Carbamazepine'. They're identical drugs and chances are, nine times out of ten, that it won't be a problem; but settling down with stability with these types of medication is important, and despite theoretical chemical identicalness, upsetting the routine can be problematic.

In some cases you may want to be specific about what you want given, too. In someone you know has a dysphagia you may want the liquid solution specifically so as to avoid any possible delay (especially on repeats where the pharmacy keeps them ordered); for children you may want to specify that amoxicillin to be provided in banana flavoured syrup. These are exceptions to the rule though, and the rest still applies: there's no call at all to be stating 'two 2.5ml spoonfuls twice a day' if you want them to have 5ml BD - it might only come with a 5ml spoon, or a graduated cup! Not a huge problem, but why would you want to be that specific?

(edited 9 years ago)

Reply 7

Etomidate

Original post by Friar Chris

Your job is not to know or research what compositions of that medicine are available and then to try and write a prescription detailing what size of tablet should be used and how many should be taken at once and what colour they should be and how many stripes should be on the capsule and...

It's quite interesting to hear a different take on this, because we've essentially been taught the opposite.

We've been told that it is our responsibility to select an appropriate preparation and strength for our prescriptions. Which, I agree, seems totally unneccesary given all the reasons you've listed. Whether this happens in real life is another matter, but this is the advice we've been given for prescribing exams.

Essentially, we're expected to damn near do everything almost down to boxing up the drugs ourselves and handing them to the patient.

Reply 8

nexttime

Original post by Etomidate

Original post by Friar Chris

...

For the electronic TTOs at my hospital it forces you to choose the exact preparation. Its really annoying as often you won't have a clue. I once prescribed an "elixir" for a 1 month old as the dosing looked most appropriate not realising that "elixir" has a technical meaning which is that it is dissolved in alcohol! However, the pharmacist will just ignore what you put and change it to whichever one they want. If its an unusual drug they'll ask you first, but if it isn't they won't. Its a pointless system.

Essentially, we're expected to damn near do everything almost down to boxing up the drugs ourselves and handing them to the patient.

Strictly not allowed in every hospital I've ever been to! :tongue:

Not that, you know, doing it anyway to clear beds without having to wait 4-6 hours for pharmacy wouldn't be an entirely logical thing to do :ninja:

(Only for salbutamol and baby feeds - wouldn't dare for anything else.)

(edited 9 years ago)

Reply 9

InArduisFouette

with regard tothe boxing and labelling comment - do the hospitals you work / are placed in not to 'discharge ready dispensing' for inpatients ? ( that of course obviously doesn;t work if you add or change meds in the run up to discharge )

Reply 10

nexttime

Original post by zippyRN

Aimed at me?

The wards I've worked on (paeds) stays were short, medication changed a lot and discharge was hard to predict. With only a few exceptions, TTOs could only really be ordered after the morning ward round, and getting hold of a single salbutamol inhaler from pharmacy would take on average >5 hours, sometimes longer. I did try to order them pre-ward round sometimes but different consultants had different approaches and tbh in about 50% of cases i would get it wrong and have to change it.

Something like elective surgery obv you would order the TTOs the day before ready for the morning.

(edited 9 years ago)

Reply 11

thegodofgod

Original post by Etomidate

I can't speak for hospital pharmacy, but in community pharmacy at least, you will probably get the FP10 sent back to you from the pharmacy if the formulation on the script isn't the correct one (e.g. doesn't exist or unavailable due to supply issues) or if it isn't stated. Simply because there is often a big difference in cost between different formulations. For example, if you prescribe: Ramipril 5 mg PO; OD, that could refer to either the 5 mg capsules (usual choice, cost: £1.22 per 28-cap pack) or the much more expensive 2.5 mg/ 5 mL oral solution (very rarely used, cost: £176.21 per 28-days).

The pharmacy only gets paid for what is on the prescription - if the formulation isn't stated on the script, the pharmacy will get paid for the cheapest formulation available on the NHS if the pharmacy is lucky, or it will not get paid at all. In most cases, especially where there are great cost differences between formulations, the pharmacy will ask the patient to get a new script for the prescriber to be more specific.

In the end it all comes down to money.

With regards to why you need to prescribe anti-epileptics and some other drugs by brand names: it's because different formulations have different bioavailabilities, and so their effectiveness can be different between different brands, even if the labelled strength is the same.

(edited 9 years ago)

Reply 12

Revenged

in hospital TTO it does not matter must as pharmacist can substitute. if you prescribe penicillin V, they can substitute if only the generic is in stock.

in the community it does matter. if you prescribe a brand like penicillin V, and the pharmacy only stocks generic phenoxymethylpenicillin, then the patient will not be given a prescription. this is one reason always to prescribe generic as patient to not like going to three pharmacy to collect medication.

regarding form, never 'tablets' or 'capsules' on a FP-10. it creates many problems in the community. if you prescribe paracetamol capsules, and the pharmacy stocks tablets only, the pharmacist again will not be able to give as the change in form is a substitution and not what was prescribed.

only write the form if you want something not typical. so olanzapine 10mg velotabs, risperidone 1mg orodispersible etc.

the exception, as mentioned, is controlled drugs. in this the form must be given, therefore you must say if you want tablets or capsules or liquid as if not it cannot be prescribed. many juniors prescribe like oxycodone 5mg take once a day, total supply 50mg (50 milligrams) - this cannot be dispensed as the form is not written. so write oxycodone 5mg take once a day, total supply 6 (six) tablets.