Fundamental Principals of Prescribing

PRESCRIPTIVE ROLE OF NURSE PRACTITIONER:

Patient needs to be refilled of medicine frequently, in that case in Western countries the patient can make
an earlier appointment with the nurse practitioner who have the authority to write prescriptions However
it differs in states what service centers practitioner can provide including whether they can prescribe
medication without physician supervision are they can only transcribe medication. Nurse practitioners
provide essential primary care services including patient routine checkups diagnosing and monitoring the
health of the Patient and recommending some treatment plan.

Prescriptive authority gives nurse practitioner more power to impact the quality of healthcare delivery. In
rural areas where primary care providers often in short supply and physician may not be present to
supervise prescription process, hence primary care providers are mainly nurse practitioners. With full
prescriptive authority nurse practitioner can prescribe medications without a lengthy process of acquiring
physician approval. Also, patient receives ready necessary medical access to treatments at reduced cost
especially in rural areas. 1906

State laws to determine Nurse practioners prescriptive authority differs considerably. Some states they
allow full practice of nurse practitioner where they may prescribe medications independently without
physician supervision. On another hand many states have restriction for the nurse practitioner to prescribe
and they require physician supervision.

Legally only a registered medical practitioner can prescribe modern medicine in India. According to national
medical Commission act 2019, Limited license have granted to community healthcare providers who are
involved with modern medical practice. Such licensed runners can prescribe in primary healthcare and
under the supervision in secondary healthcare. It also limits number of licenses granted comment
healthcare providers not to be more than 1/3 of the license to medical doctors. Prescribing drugs is a
complex task which requires clinical knowledge diagnostic skills decision making to capacity considering the
patient condition and the knowledge of commonly used medicines. According to the policy of the
organization, Nurse can transcribe doctor's prescription to the nurse’s chart and raise request to the
pharmacy within the hospital system. They can transcribe drug name, dose, strength, route, frequency. In
this case if any error occurs it is known as transcription error.

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LEGAL AND ETHICAL ISSUES RELATED TO PRESCRIBING:

LEGAL ISSUES

Standing orders:

In some sectors, certain physician are allowed to write standing orders that acts like a prescription for
everyone in the general public. These orders will provide a standard procedure for determining the
necessity and details for safe administration of drugs. These are typically used to authorize certain people
to perform preventive, low risk or emergency care that would be otherwise logistically cumbersome to
authorize for individual patients including vaccination, prevention of cavities, birth control, treatment of
infectious disease and reversal of drug doses etc.

Legibility of handwritten prescriptions:

Doctors handwriting is a reference to the pharmacist. stereotypically illegible handwriting of some medical
practitioners sometime causes error in dispensing. Thus, it is legislatively required that the prescription
should be legible and even the Institution of safe medication practices advocated the elimination of
handwritten prescriptions altogether. Prescription is a medico legal document for the treatment given by
the doctor to the patient so it should be a rational legible with all necessary information to the pharmacist
and the patient.

Rational prescription:

Rational prescription means the patient weather receives treatment based on the individual medical need
with appropriate dose and duration at the reasonable cost. irrational prescription can lead to the poor
quality of care increase drug resistance adverse reaction cost mortality and morbidity. also, the patient loses
trust in treating doctors. in India the drugs and cosmetics act 1940 and the drug schedules are widely
followed for all prescriptions.

Medical negligence:

It is the harm caused to the patient by a medical practitioner by not providing the necessary care to the
patient.

Avoiding ambiguity:

Prescribers must follow certain conventions for prescription writing to avoid ambiguities and
misinterpretation this includes,

• Careful use of decimal points. Avoid unnecessary decimal points such as 5 ml rather than 5.0 ml. it
may be misinterpreted as 50 ml.

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 • Use of apothecary system and symbols of measures should not be allowed to prevent confusion.
Pints (O) if written can be confused zero (0).
• Directions written out in full in English.
• Where the directions are "as needed" then the quantity should always be specified.
• Use of permanent ink is encouraged.
• Units in the form of teaspoon or tablespoon should be avoided.
• The degree symbol used commonly for abbreviation of hours should not be used as it can be
confused as zero.

Abbreviations:

Many abbreviations derived from Latin phrases. Some abbreviations that are ambiguous or that in their
written form might be confused with something else are not recommended and should be avoided. All
abbreviation carries and increase risk for confusion unresectable and should be used cautiously.

Ethical issues:

Treating doctors and other healthcare professionals are also bounded by certain ethical principles.

The following ethical principles are,

• Respect to autonomy: An adult patient who is mentally sound has the right to make all decision
regarding his/her health, disease, and treatment. Informed concern must be taken from the patient
for any diagnostic treatment methods unconfident quality of the patient must be maintained.
• Non maleficence: This principle explains that no intentional harm or injury to be done to the patient
or society.
• Beneficence: Health professionals should act for the benefit of the patient.
• Justice: Physician must treat all the patients equally and fairly.

The treating medical professionals should share all the necessary information about the medical condition
of the patient so that he or she makes an informed decision and there is mutual understanding and
agreement on the treatment plan.

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FUNDAMENTAL PRINCIPLES OF PRESCRIBING

Prescribing is the main approach to the treatment and prevention of disease in modern healthcare. While
medicines have the capacity to enhance health, all have the potential to cause harm if used inappropriately.
We recommend that health care professionals who prescribe medicines should do so based on the following
ten principles, which underpin safe and effective use of medicines.

All prescribers should:

Be clear about the reasons for prescribing: It is an establish an accurate diagnosis whenever possible
(although this may often be difficult) It should be clear in what way the patient is likely to gain from the
prescribed medicines.

Consider the patient's medication history before prescribing: It is obtained an accurate list of current and
recent medications (including over the counter and alternative medicines); prior adverse drug reactions;
and drug allergies from the patient, their careers, or colleagues. Health care providers should consider that
medicines play an important role in the doctor-patient relationship, and should try to enlist, recruit, and
involve the patient in a collaboration related to the prescribed medication. The psychological implications
of receiving a drug therapy should be discussed and considered.

Consider other factors that might alter the benefits and risks of treatment: It should be considered other
individual factors that might influence the prescription (for example, physiological changes with age and
pregnancy, or impaired kidney, liver, or heart function) The decision to prescribe a pharmacological
treatment must take into consideration the potential risks and benefits to each individual patient. Health
care providers should discuss with patients, family members and/or patients' carers these potential risks
and benefits.

Consider the patient's ideas, concerns, and expectations: It Seeks to form a partnership with the patient
when selecting treatments, making sure that they understand and agree with the reasons for taking the
medicine.

Select effective, safe, and cost-effective medicines individualized for the patient: It is likely beneficial effect
of the medicine should outweigh the extent of any potential harms, and whenever possible this judgement
should be based on published evidence in general, health care providers and patients should consider that
most psychiatric disorders can effectively be tackled by means of pharmacological and non-pharmacological
interventions. The decision to prescribe a psychotropic agent never implies that psychological and/or
psychosocial interventions are not indicated. Evidence has consistently shown that combining medicines
with psychosocial interventions tends to be associated with better outcome. Consequently, health care
providers should not passively consider medications as their only therapeutic strategy, and patients should
not be given a message suggesting that modifications of thought, mood and conduct can be achieved by

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pharmacological means only. Articulated, comprehensive and individualized treatment plans may represent
the best therapeutic option.

Selection of medicine: The Prescribe medicines that are unlicensed, 'off label', or outside standard practice
only if satisfied that an alternative medicine would not meet the patient's needs (this decision will be based
on evidence and/or experience of their safety and efficacy) and choose the best formulation, dose,
frequency, route of administration, and duration of treatment.

Adhere to national guidelines and local formularies where appropriate: It should be be aware of guidance
produced by respected bodies (increasingly available via decision support systems), but always consider the
individual needs of the patient. The Selected medicines about costs and needs of other patients (health
care resources are finite) The dosages listed in this publication are mainly based on data available from
countries and health care providers prescribing psychotropic medicines for their patients in other parts of
the world should be aware of inter-individual as well as ethnic differences in drug metabolism. Health care
providers should always consult the national or local prescribing information or instructional material. The
term "milligrams" has been abbreviated in mg throughout the text. It should be able to identify, access, and
use reliable and validated sources of information (for example, British National Formulary), and evaluate
potentially less reliable information critically.

Write unambiguous legal prescriptions using the correct documentation: It should be aware of common
factors that cause medication errors and know how to avoid them.

Monitor the beneficial and adverse effects of medicines: It is Identify how the beneficial and adverse
effects of treatment can be assessed. To understand how to alter the prescription because of this
information. It should know how to report adverse drug reactions (in the UK via the Yellow Card scheme).

Communicate and document prescribing decisions and the reasons for them. The Communicate should be
cleared with patients, their careers, and colleagues. Prescriber should give patients important information
about how to take the medicine, what benefits might arise, the adverse effects (especially those that will
require urgent review), and any monitoring that is required. Use the health record and other means to
document prescribing decisions accurately.

Prescribe within the limitations of your knowledge, skills, and experience: It Always seek to keep the
knowledge and skills that are relevant to your practice up to date. It should Be prepared to seek the advice
and support of suitably qualified professional colleagues. It should be Make sure that, where appropriate,
prescriptions are checked (for example, calculations of intravenous doses.

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STEPS IN PRESCRIBING:

WHO has given guide to good prescribing which provides an attractive and effective 6 step methodology. In
many medical curriculums teaching is focused mainly on symptoms and diagnosis and the little or no time
is given to the principles of drug treatment. Unfortunately, some medical schools still provide only short
courses in pharmacotherapy during their curriculum and internship. In last 20 years several initiatives have
been taken to improve the undergraduate teaching of pharmacology, clinical pharmacology, and
pharmacotherapy emphasis on increasing therapeutic knowledge and skills often in preclinical phase.

To facilitate the teaching of rational prescribing WHO action programmed on essential drug developed in
collaboration with university of Groningen has given manual for undergraduate medical students that gives
the principles of rational prescribing called "guide to good prescribing."

This Manual presence with normative model for therapeutic reasoning and prescribing in the form of 6 step
model of rational prescribing:

Step 1: Define the patient problem.

Step 2: Specify the therapeutic objective.

Step 3A: Choose your standard treatment (P-drug).

Step 3B: Verify the suitability of your treatment (P drug).

Step 4: Start treatment.

Step 5: Give information instructions and warnings.

Step 6: Monitor and stop treatment.

Step 1: the first step is to define the patient problem clearly and must be evaluated with patient’s symptoms
complaints any relevant characteristics such as drug allergy, concomitant medication history, any
comorbidities, pregnancy, lactation etc. This step forms the basis for choosing and prescribing the correct
treatment during the further steps.

Step 2: the second step is to specify the therapeutic object which is required for designing the right
treatment and for monitoring the effect of treatment on step 6. Without clearly specified therapeutic
objectives it is not possible to adequately monitor treatment that results in incorrect conclusion and further
actions.

Step 3: the 3rd step is to choose which drug or treatment is needed. Here they stepped 3 is divided into 2
parts WHO as, the first drug of choice should be selected based on the specific indication (step up 3A) and

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then confirm its suitability for the patient condition considering the factors mentioned in step 1 (step 3B)
The term P drug indicate prescribers’ personal drug of choice.

Step 4: Verifying the suitability of P drug for an individual after checking thoroughly about patient
symptoms, complaints, relevant characteristics, drug allergy, medication History, comorbidity, pregnancy,
lactation etc. Once an appropriate drug has been chosen for the patient it needs to be administered
correctly. This involves writing the prescription and starting the treatment.

Step 5 Giving the patient information, instructions, precautions, and Contra indications about the
treatment.

Step 6: The treatment given to the patient should be monitored for the effectiveness of treatment and the
follow up should be done. This step includes decisions about whether to continue, adjust or stop the
treatment.

This 6-step approach describes about the 3 therapeutic skills to be considered to reflect therapeutic
competency as cognitive, communicative, and motor skills. These skills are selecting the treatment
(cognitive), giving the patient information and instruction (communicative) administering the drugs(motor)
respectively.

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PRESCRIBING COMPETENCIES:

To prescribe the drugs with healthcare professionals should have the knowledge and be competent. He/
she should acquire the following prescribing competencies are.

This framework consists of 1 to 5 competency areas based on the person-centered prescribing.

Competency area 1: understand the patient and their needs.

• Ensure competency to assist the patient needs.

• Discuss with the patient regarding their medical and treatment history.
• Assess the person according to the clinical context and the health professional's scope of practice.
• Consider the patients cultural history and identify the patient needs.
• Review and interpret the information in the patient health record contribute an understanding of
their needs and current treatment. to
• Explorer with the person their adherence to prescribed medicines and the treatment plan.
• Review and understand the diagnosis and key clinical issues including those that are or maybe
medicine related.
• Discuss with the person the clinical issues and the implications for treatment.

Competency area 2: understand the management options.

• Recognize when it is clinically appropriate not to prescribe medicine.

• Review current medications and consider the possibility of a contribution to current health issues.
• When treatment is indicated consider both non pharmaco- logical and pharmacological options
• Identify suitable medication options.
• Obtain, time interpret and apply current, reliable evidence and information about medicines to
inform decision making.
• Consult other healthcare professionals also about potential medicines and their treatment plan
where appropriate.
• Tailor medicines for the person considering relevant potential benefits, harms, medicines, and
person- specific factors.
• Consider the financial cost and affordability of the medicine to the patient.
• Consider the implications to the wider community of prescribing a particular medication.
• Refer the person for further assessment or treatment when the suitable treatment options are
outside the healthcare Professional's scope of practice.

Competency area 3: agree on a plan for medication.

• Explore the person's opinion and preferences about medicines and their treatment plan.

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 • Negotiate the therapeutic goals that enhance self-management.
• Discuss the possible medicine options with the person and allow them time to make an informed
decision.
• Explore and respond appropriately to the patient concerns and expectations about their health and
the use of medicines to maintain their health.
• Develop the medicine plan in partnership with the patient.

Competency area 4: prescribe the medicines and communicate the agreed treatment decisions.

• Ensure adequate and current knowledge of medicines prior to prescribing.

• Prescribed medicines complaint with relevant legislation, regulatory framework, guidelines, code
of practice, scope of practice and organizational policies and procedures.
• Where prescribing relies on electronic or telephonic devices ensure compliance with the relevant
legislation guidelines and policies.
• Provide accurate and complete information to healthcare professionals in a timely manner when
implementing new medicines or modifying the existing medicines or treatment plant.
• Discuss and document that treatment plan with the person and ensure they understood both the
plan and how to use them medicine safely and effectively.

Competency area 5: review the outcomes of treatment.

• Explore with the person their response to treatment including adherence to the medicines and
treatment plan.
• Gather the objective information using appropriate indicators to assess the response to medicines
wherever appropriate.
• Synthesis information provided by the person, other healthcare professionals and form the
assessment to determine the response to medicines.
• Discontinue or modify existing medication or other treatment where appropriate.
• Discuss with the person the benefits of the medication management review where appropriate.
• Work with the person and other healthcare professionals to modify the treatment plan to optimise
safety and effectiveness of treatment their appropriate.
• Discuss the findings of the review and recommendation with other healthcare professionals where
appropriate.

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Competency area 6: Prescribe safely and effectively.

• Understand and prescribe medicines according to the relevant legislation regulatory framework and
organizational recruitments.
• Practice within the limits of the healthcare professional's education training and scope of practice
as applied prescribing.
• Understand common cause of incidents and error associated with the prescribing and medicines
use and implement strategies to reduce the risk of these occurring.
• Detect and report errors, incidence and adverse events involving medicines.
• Apply quality use of medicine principles when prescribing medicines.
• Critically evaluate information about the medicines and make evidence-based decisions in the
context of patient needs.

Competency area 7: Prescribe professionally.

• Understand and comply with the applicable professional standards code of conduct and guidelines
relevant to prescribing.
• Demonstrate appropriate professional judgement when interpreting and applying prescribing
guidelines and protocols to the patient situation.
• Ensure the persons need take precedence overall consideration in all prescribing decisions.
• Demonstrate respect for other healthcare professionals and their contribution within a
collaborative care model.
• Maintain accurate and complete records of the interaction.
• Accept responsibility and accountability for prescribing decisions.
• Increase in ongoing professional development and education to improve prescribing practice.

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