Education
An introduction to prescribing
Writing a safe, effective, and legal prescription
By: Daniel R Burrage
Published: 27 noviembre 2014
DOI: 10.1136/sbmj.g6191
Cite this as: Student BMJ 2014;22:g6191
Respond to this article
In this article:
Tables:
Figures:
Boxes:
Box 1: Key prescribing skills
Box 2:Key points for Prescribing Safety Assessment
Box 3: World Health Organizations six step approach to prescribing9
Box 4: Legal requirements for a valid prescription
Box 5: Other essentials for a valid prescription
Box 6: Good prescribing practice
Box 7: Where to write on the drug chart
Resources and further information
How to approach the prescribing request
Prescribing is an essential skill that medical students must learn. It
has the potential to improve health, but is associated with risk to
patients. The EQUIP study reported that newly qualified doctors had
a prescribing error rate of 8.4%, and drug errors account for more
than 10% of incident reports a year.[1] [2] The most frequent errors
are caused by incorrect dosage; common drug classes involved are
analgesics, antibiotics, bronchodilators, and antianginals, with most
errors being made on acute admissions.[1]
Undergraduate training should prepare students for their
responsibilities as newly qualified doctors, but around half of
graduates feel unprepared,[3] [4] [5] particularly in areas of practice
that are based on experiential learning such as prescribing.[6]
The General Medical Council (GMC) outlines eight key prescribing
skills (box 1).[3] These form the basis of the national Prescribing
Safety Assessment (PSA) (box 2), which aims to ensure that all
students obtain core prescribing competences by the point of
graduation.[7] The PSA is compulsory in several medical schools,
where it is used as part of finals exams, and it is likely that the
number of medical schools using it in this way will increase. This
article will help you with the first component of the assessment by
demonstrating how to plan appropriate drug treatment and provide a
safe and legal prescription. It will provide a starting point for how to
identify the most important drugs you need to be familiar with, what
you need to consider when deciding what to prescribe, and how to
prescribe it.
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Box 1: Key prescribing skills
Establish an accurate drug history, covering both prescribed and other drugs
Plan appropriate drug treatment for common indications, including pain and distress
Provide a safe and legal prescription
Calculate appropriate drug doses and record the outcome accurately
Provide patients with appropriate information about their medicines
Access reliable information about medicines
Detect and report adverse drug reactions
Demonstrate awareness that many patients use complementary and alternative therapies
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Box 2: Key points for Prescribing Safety Assessment
Prescription is a form of communication between the prescriber, the pharmacist, and the person
administering the drug
Becoming familiar with the pharmacology, prescribing information and characteristics of a core list of drugs
can improve prescribing skills
The WHO six step approach to prescribing helps to break down the task of prescribing into manageable
chunks
Every prescription must meet a minimum set of legal requirements, and in addition must contain enough
information for the medicine to be administered as intended
Adhering to good prescribing principles can help reduce errors
Practising prescribing, including using guidelines and resources such as the BNF, will help prepare you as a
newly qualified doctor
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Student formulary
Developing a core list of drugs to learn can help make the process of
prescribing less overwhelming and improve prescribing skills.[8] The
World Health Organization (WHO) recommends that students
develop their own list of personal drugs, which they are likely to
prescribe regularly, and with which they should become familiar.
[9] This can be difficult when you are confronted with hundreds of
drugs that come in many formulations. Lists compiled by tutors can
be just as useful, and a list of the top 100 drugs most commonly
used in clinical practice is a good starting point.[10] The top five
drugs prescribed by general practitioners in 2013 were simvastatin,
aspirin, levothyroxine, omeprazole, and ramipril.[11]
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Planning appropriate treatment
Deciding what to prescribe requires knowledge of your patient, his or
her diagnosis, the treatments available, and how they work. Often,
no one right answer exists. Decisions depend first on the patient:
age, physiology, comorbidities, other drugs being taken, allergies,
and patient choice; and second, the prescriber: their knowledge,
experience, and preferences. Decision making is also informed by
national guidelines, national formulariesfor example, theBritish
National Formulary (BNF)and your local formularythe medicines
available to you at your institution.
Other factors to help you choose are the relative balance of benefits
versus risk of different drugs, the desired route of administration, and
cost. For example, when choosing a non-steroidal anti-inflammatory
drug (NSAID) to treat an episode of acute gout you will have to pick
one from a potential choice of 20 or more listed in the BNF. Your
choice is reduced when you identify that some are only licensed for
specific diseases such as migraine or ankylosing spondylitis. You
should then consider any major cautions or contraindications, such
as cardiovascular disease. Current evidence suggests that, among
the various NSAIDs available, naproxen is least likely to precipitate
adverse cardiovascular events, so has a more favourable side effect
profile. It is also available in non-proprietary form and is among the
least expensive.
The WHO suggests a six step approach to prescribing (box 3).[9] In
step one you should identify the problem you are trying to solve, and
in step two you should specify the aim of treatment. This could be
symptomatic relief, treatment of the underlying disease process,
prevention of disease, maintenance of health, or improving
prognosis or both.
In step 3 you must identify a safe, effective treatment, which relies
on your knowledge of the best current evidence. It is important to
recognise the limits of your knowledge and experience here. When
you start out prescribing it is likely, and expected, that you will often
need to seek senior advice or refer to local or national guidelines
when deciding what drug to choose.
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Box 3: World Health Organizations six step approach to
prescribing[9]
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Planning appropriate therapy
1. Define the patients problem or diagnosis
2. Specify the therapeutic objective
3. Choose a treatment of proven efficacy and safety
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Providing a safe and legal prescription
4. Start the treatmentadvise and explain first in a way the patient can understand; drug name, dose,
quantity, frequency and timing, date, signature, and patient identifier. Write clearly (this is a legal duty)
5. Provide the patient with clear information and instructions (effects of drug, side effects, instructions,
warnings, next appointment, everything clear)
6. Monitor the results of treatment (efficacy, safety, tolerability) and review if and when it can be stopped
When you have chosen a drug, you must decide on a dose, which is
the quantity to be taken at a single time point. This can be difficult,
and you should refer to guidelines where available and the BNF.
The BNF often provides a dose range, which can vary for a
particular drug depending on the indication.
A rough rule of thumb for chronic conditions is to start at the lower
end of this range and then increase the dose over time to achieve
the desired clinical effect, while minimising adverse effects to the
patient. For example when starting an angiotensin converting
enzyme (ACE) inhibitor, such as ramipril for chronic heart failure, it is
common practice to start at a low dose, for example 1.25 mg daily,
and then increase the dose over a period of weeks to 10 mg daily if
there have not been any severe side effects.
For acute conditions, the inverse is often true. You might want to
start by giving a high dose of a drug and then wean down. For
example in acute heart failure, you could prescribe a high dose of
furosemidefor example, 80 mg dailyand then gradually reduce
the dose over days to weeks as symptoms improve. The route you
choose can also affect the dose you give. Furosemide has roughly
double the potency when given at the same dose intravenously
compared with orally.
Other factors that can determine dose include drug-drug
interactions, patient body weight, and special circumstances such as
pregnancy, renal impairment, and hepatic impairment. Prescribing
for children frequently requires specific dosing according to weight or
body surface area. It is not expected that you will know all doses off
by heart, but you should recognise factors that can influence dosing
and refer to resources such as the BNF and pharmacists to assist
you in making the best decision.
When you have decided on a dose, you must then specify the
frequency and route of administration, and the formulation of the
drug where relevantfor example, morphine sulphate comes in
tablet and liquid formulations.
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Providing a safe and legal prescription
Prescriptions may be handwritten or prescribed electronically with
the support of a database of drugs. Irrespective of the format there
are key components that are required to make any prescription legal
(box 4).
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Box 4: Legal requirements for a valid prescription
Written legibly
Written indelibly
Dated
Name and address of patient (or hospital number for inpatients) to be given, and ideally date of birth
Address of prescriber (or contact details for hospital prescribers) is stated
Signed by the prescriber
Besides the legal requirements for a prescription, specific details are
required to instruct a pharmacist or nurse on how to dispense and
administer the drug (box 5). To minimise errors, you should avoid
abbreviations, and give additional instructions where required (box 6,
tables 1 and 2 ).
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Box 5: Other essentials for a valid prescription
AllergiesDocument, and take into account, drug allergies and intolerances
Drug nameWrite drug names clearly, preferably in capitals and do not abbreviate. Use approved drug
names, as per the BNF. Non-proprietary names are preferable where given in the BNF, but in some circumstances
brand names could be more appropriatefor example, where there are differences in clinical effect between different
manufacturers formulations, such as antiepileptics
Drug strengthState strength where applicable. For example, beclomethasone inhalers come in strengths
including 50 micrograms, 100 micrograms, 200 micrograms, and 250 micrograms
Drug dosageState dose, frequency, and duration. Also, where applicable, state quantity, that is, for
outpatient or community or discharge prescriptions
Route of administrationMost drugs are only available to be administered by one or two routes, but
nonetheless you should clearly state the route of administration as this can influence dose (for example, metoprolol)
and instructions for the patient (for example, mesalazine tablets versus enema)
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Box 6: Good prescribing practice
Avoid unnecessary use of decimal points to avoid ambiguityfor example, write 125 micrograms rather
than 0.125 mg. Where the use of a decimal point is unavoidable ensure it is preceded by a whole numberthat is,
0.125 mg rather than .125mg
Do not abbreviate micrograms, nanograms, or units. Acceptable abbreviations include: milligrams (mg),
grams (g), tablets (tab(s)), millilitres (mL), litres (L), millimoles (mmol)
When prescribing as required drugs state a minimum dose intervalthat is, paracetamol 1 g, oral, four
times daily, minimum dose interval 4 hourly, maximum dose 4 g in 24 hours
Give instructions in English without abbreviation, although some Latin abbreviations are recognised and
commonly used (table 1)
Provide start and review/stop dates where appropriate, particularly for short course treatments such as
analgesics and antibiotics
Additional information or instructions can also be useful. For example, it is good practice to state the
indication for an antibiotic.
Latin, abbreviation
Latin, in full
Preferred instruction
od
omni die
Daily
om
omni mane
Every morning
on
omni nocte
Every night
bd
bis die
Twice daily
tds
ter die sumendum
Three times daily
qds
quater die sumendum
Four times daily
prn
pro re nata
As required
Route
Abbreviation Definition
Buccal
buccal
Directed toward the cheek, from within the
mouth
Intramuscular
im
Within a muscle
Intravenous
iv
Within or into a vein or veins
Intravenous bolus
iv bolus
Within or into a vein or veins all at once
Nasal
nasal
To the nose
Nasogastric
ng
By means of a nasogastric tube
Oral
oral
By way of the mouth
Percutaneous endoscopic
gastrostomy
peg
By means of a percutaneous endoscopic
gastrostomy tube
Rectal
pr
To the rectum
Subcutaneous
sc
Beneath the skin
Sublingual
sl
Beneath the tongue
Topical
topic
To the outer surface of the body
Vaginal
pv
To the vagina
One area of anxiety can be identifying the correct place to prescribe
on the chart, which is compounded by substantial variation nationally
in the design of drug charts. It is important you familiarise yourself
with the charts used in your hospital. Some general guidance is
given in box 7.
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Box 7: Where to write on the drug chart
Drug allergies and intolerancesDocument (and remember to take into account) all allergies and
intolerances that you elicit from your history and other sources such as medical records, the patients general
practitioner, and pharmacists. Where known, document the reaction too
Once only drugsPrescribe drugs in the once only section when they are intended to be given as a one-off
(for example, a sedative given as premedication before an operation) or when you would like a drug to be
administered immediately (for example, an emergency drug such as lorazepam for a seizure)
Regular drugsIn the regular section, prescribe the patients usual drugs and any new ones required as a
short course or that are expected to continue
InfusionsUse the infusion section of a chart to prescribe fluids or drugs that will be administered as an
infusion (for example, glyceryl trinitrate infusion for the relief of acute pulmonary oedema)
As requiredUse this section for drugs that do not need to be administered regularly, but may be
administered at the discretion of nursing staff, usually for symptomatic relief (for example, analgesia for breakthrough
pain). You should remind patients that as required medicines are available and they can ask for them when needed if
they are inpatients
OxygenOxygen should be prescribed in a designated section of the drug chart when indicated
Additional chartsSome drugs may be prescribed on additional charts. This commonly includes
anticoagulants, insulin, and blood products. Substantial variability occurs nationally as to how this is done, so you
should familiarise yourself with local charts
Prescribing has many more complexities that are beyond the scope
of this introductory article. These include prescribing a drug that
comes in more than one formulationfor example, modified release
preparations. Controlled drugs, such as strong opiates like
morphine, require special regulation, and additional information,
such as the total quantity to be supplied in words and figures. Skills
in prescribing these drugs will develop as you become a more
experienced prescriber, and you should seek advice from senior
colleagues and pharmacists to help.
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Conclusion
Prescribing is complex, and opportunities to practise as a student
can be limited. Learning about prescribing, however, occurs through
experience. It is therefore important to practise just as you would
with other clinical skills. This will prepare you for exams, but more
importantly for when you start as a doctor.
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Resources and further information
British National Formulary (www.bnf.org)
WHO Guide to Good Prescribing (http://apps.who.int/medicinedocs/pdf/whozip23e/whozip23e.pdf )a
practical manual
Develop a core drug list to improve prescribing education and reduce errors in the UK
National Institute for Health and Care Excellence (www.nice.org.uk)
Prescribing Safety Assessment (box 2)
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Practice case and answer
A 26 year old man presented to the emergency department
overnight with sudden onset shortness of breath and pain on
breathing on the right side of his chest. He had no significant past
medical history. He did not take any regular medication. He had
previously developed a rash after taking ibuprofen. He was a music
teacher and lived independently.
On examination he was afebrile; heart rate was 88 beats/min and
regular; blood pressure 128/68; respiratory rate 20 breaths/min;
oxygen saturations 100% on 28% oxygen via Venturi mask. His
trachea was central, percussion was resonant throughout the chest,
and there was reduced air entry in the right lung. A chest radiograph
revealed a large right sided spontaneous pneumothorax.
Pleural aspiration was unsuccessful, so at 4 pm an intercostal drain
was successfully inserted using local anaesthetic with no immediate
complications. A couple of hours after the procedure he complained
of a gradual recurrence of the discomfort on the right side of his
chest despite regular paracetamol. He rated the pain as 5/10 in
severity.
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Task
Your registrar has reassessed the patient and suspects the pain has
recurred as the effect of the local anaesthetic wearing off. She
advises you to write a regular prescription for one further drug to
alleviate his pain (fig 1). 1
Fig 1 Current drug chart, showing prescription for paracetamol (frequency of administration is circled)
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How to approach the prescribing request
It is useful to use the WHO six step approach to tackle this prescribing task (box 3).
1. Define the problemThe patients problem is chest wall pain after the insertion of a chest drain for a
spontaneous primary pneumothorax. It is important to consider whether the pain is proportionate to the procedure
and pneumothorax or whether it may signal a complication. You should therefore make a full assessment while also
providing symptomatic relief. In this case a senior colleague has reviewed the patient and has advised that this is
probably recurrent pain from the pneumothorax and drain insertion as the local anaesthetic has started to wear off.
2. Specify the therapeutic objectiveRelief of the pain.
3. Choose a treatmentWHOs pain ladder (www.who.int/cancer/palliative/painladder/en/) gives a useful
guide on how to escalate treatment for pain. The first step advises non-opioid treatments such as paracetamol and
non-steroidal inflammatory drugs (NSAIDs). In this case paracetamol has not been sufficient and the patient has
previously had an allergic reaction to an NSAID so it would not be advisable to prescribe another one, particularly if
other options are available. The next step on the ladder advises mild to moderate opioids, which include codeine,
dihydrocodeine, and tramadol. These exist in formulations as single drugs, but also as combination preparations with
paracetamol, e.g. co-codamol, co-dydramol. Any of these would be appropriate as an additional analgesic. If you
prescribe a compound preparation that contains paracetamol, stop the existing paracetamol prescription, to avoid
accidental overdosage, by crossing it off the drug chart, and sign and date this change.
4. Start the treatmentMake sure you have explained to the patient how you intend to relieve his pain.
Then write the drug name, dose, frequency and timing, start date, and sign the prescription.
To choose a dose refer to the BNF. An example prescription is given in figure 2 2 . Acceptable answers
would include:
Continue regular paracetamol and start: Codeine 30-60 mg orally 6 hourly Dihydrocodeine 30mg orally 6
hourly Tramadol 50-100mg orally 6 hourly. Or stop the regular paracetamol and start: Co-codamol 15/500, 1-2 tablets
orally 6 hourly Co-codamol 30/500, 1-2 tablets orally 6 hourly Co-dydramol 10/500, 1-2 tablets orally 6 hourly
5. Provide the patient with clear information and instructionsExplain that you are offering a painkiller that
is a weaker version of morphine. It will be given at regular intervals. A common side effect is constipation, and he may
require a laxative. Some patients become drowsy and confused when starting a new painkiller, so if he goes home on
an opioid he should avoid driving or operating heavy machinery.
6. Monitor the resultsReview his symptoms after about one hour to check the pain is improving.
Fig 2 Drug chartsample answer
Daniel R Burrage, specialty registrar (ST4), clinical pharmacology, general medicine and stroke medicine
1
St Georges Healthcare NHS Trust, London
Correspondence to: dburrage@sgul.ac.uk
Competing interests: We have read and understood the BMJ policy
on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; externally peer
reviewed.
References
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National Patient Safety Agency. National reporting and learning system quarterly data workbook.
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British Pharmacological Society. The prescribing safety assessment.
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Cite this as: Student BMJ 2014;22:g6191
