II.DRUG PRESCRIBING. After the best drug has been selected and a therapeutic regimen desig

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II.DRUG PRESCRIBING. After the best drug has been selected and a therapeutic regimen designed, a chart order (for patients in the hospital) or prescription (for outpatients) must be written. * Chart orders must contain the date, the drug, the dosage to be administered, and the name of the physician writing the or- der. Normally every page in the chart is stamped with the name of the patient to reduce the possibility of the wrong patient receiving the drug. It is good practice (most would consider it essential) to specify the duration of therapy, ie, total number of doses or days of treatment. Orders to run indefinitely should be avoided and in many hospitals are sub- ject to automatic stop orders. Most hospitals have a pharmacy committee that determines for each drug whether generic or the more expensive proprietary formulations are to be stocked as well as other matters pertaining to drug use. Such in- formation is usually found in the official formulary of the institution. (PgDn key for more text) * Prescriptions must contain the patient's name and address, the prescriber's name and identifying information, and the name and dosage form of the drug, the amount to be dispensed, and directions to the patient for use. Formulation size or concentration should be specified in metric units. For con- trolled drugs (drugs regulated by ``narcotics laws''), the prescriber's DEA (Drug Enforcement Agency) license number must be displayed. In some states, special prescription blanks must be used for Class II agents (the most rigidly controlled drugs, see . The prescriber should al- ways provide his printed name, address, and telephone number in addition to his signature, in case the pharmacist needs to reach him. In many states, the law permits the pharmacist to substitute a generic equivalent for the named drug unless the prescription bears a ``as written'' or ``no substitution'' flag. Thus, the cheaper generic forms of hydrochlorothiazide could legally be substituted for Hydrodiuril(tm) at a cost savings of about 50% to the patient. (PgDn key for more text) This flexibility does not, however, extend to the substitution of a congeneric compound, eg, hydrochlorothiazide for polythiazide, even though the pharmacologic effect would be identical. The therapeutic equivalence of trademarked and generic drugs is monitored by the FDA and the results published (Approved Drug Products With Therapeutic Equivalence Evaluations, 1985, and updates). Finally, it is good practice to explicitly specify the number of refills to be permitted for all drugs (this is required for controlled drugs). Prescribing categories. The tables in this book list prescribing codes for each drug. These codes are in the form ``controlled drug category; pregnancy safety category.'' The classification of the drug un- der the controlled substances act (``narcotics laws'') determines the type of prescription form that must be used, the number of refills permitted, etc. (PgDn key for more text) This system is summarized in . 旼컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴커 To look at tab1-1 quickly, press the up or the down arrow key [on the number keypad at the right side of the keyboard] so that the "tab1-1" appears in reverse video, and then press the Enter key. Return to this text by pressing the left arrow key on the same keypad. 읕컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴컴켸 If a drug is available to the public without pres- cription (``over the counter''), it is coded ``otc.'' If it is a prescription item, but not controlled under the narcotics laws, it is listed as an ``Rx'' item. If the drug is covered under the narcotics laws, the control level (C-II,III,IV, or V) is shown. This designation, therefore, is of considerable direct legal significance for every prescription written. The second part of the code is the FDA pregnancy prescribing category and is based on the definitions given in . The pregnancy category is an attempt to codify the benefit-risk aspects of the use of a given drug during pregnancy. Its legal significance is in the implicit liability involved if the drug is so used and a mal- practice suit results. (PgDn key for more text) Follow-up after the patient has received the prescription. The prescriber's responsibility continues long after writ- ing the prescription. He or she must then determine whether the patient is taking the drug, monitor the response to establish whether the drug is accomplishing its therapeutic goals, and de- cide when to discontinue or modify the therapy. References 1. Drug Topics RedBook, Medical Economics, Inc, 1986, 1987. 2. Facts and Comparisons, JP Lippincott, 1987. 3. Generic drugs. Med Lett 1986;28:1. 4. Hospital Formulary, 1985-1987. University of California Hos- pitals and Clinics, 1985. 5. Hansten, PD: Drug Interactions, 5th edition, Lea & Febiger, 1985. 6. Katzung BG, ed: Basic & Clinical Pharmacology, Appleton & Lange,third edition, 1987. 7. Krupp MA, Schroeder SA, Tierney LM, jr: Current Medical Diag- nosis & Treatment, Appleton & Lange, 1987. (PgDn key for more references) 8. Prescription practices and regulatory agencies. Chapter 1 in AMA Drug Evaluations, 6th ed, 1986, pp 1-11. 9. USP DI: Drug Information for the Health Care Provider. Sixth ed. United States Pharacopeial Convention, Inc, 1986. (Home key to return to top of file)


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