Dr David Wood

Consultant Physician and Clinical Toxicologist

Guy’s and St Thomas’ NHS Foundation Trust,

London

How to write a drug chart

... properly!

LECTURE EXTRACT FOR PHASE

3

Key Steps in Prescribing

1. Ensure it is the right patient

2. Always write legibly

3. Sign and date everything you do

4. Check the allergy status before prescribing

anything

5. Check that you aren’t duplicating prescriptions

6. If are unsure ask about or look up doses,

frequencies and/or the drug you are prescribing

7. Take time when prescribing!

Area for patient

identification

Use hospital sticker

If no stickers then write:

– Name

– Date of Birth

– Hospital Number

ALLERGY SECTION

MUST BE FILLED IN

FOR EVERY PATIENT

BEFORE YOU WRITE

ANYTHING ELSE

Document what the

allergy is

Sign and date the entry

Don’t forget to alter

entry if patient develops

allergy

ONCE ONLY

PRESCRIPTIONS

Always date AND time

that you want drugs to be

given

First dose antibiotics

should be prescribed here

(Surviving Sepsis

campaign) – improves

number given within an

hour

ANTICOAGULANT

PRESCRIBING

Ensure you check the INR

result before prescribing

Warfarin

Be aware of the GSTFT

anticoagulant guideline on

how to correctly initiate

and continue Warfarin

therapy

Medicines Reconciliation

Nearly last page .....

but one of most

important

Ensure accurate drug

history prior to

admission

– GP

– Old letters (EPR)

– Pharmacy help

Drugs Not Given

Usually completed by

nursing staff

– Indicates reason(s)

for drugs not being

given

– Check on a regular

basis – is it because

your patient is “nil by

mouth”?

Regular Prescriptions:Key Components Part 1

Drug Name

Date of prescription

Dose

Duration of treatment

Route

Signature (AND NAME)

Check the patient’s name/allergy status first

Write legibly and preferably in block capitals

Use generic drug names not trade names

Dose and route have to legible

Sign and print you name for each prescription

Do not abbreviate micrograms and units

- Space between units and dose

Try not to use decimal points

Put a duration for drugs such as antibiotics

Key Components Part 1

Regular Prescriptions:Key Components Part 2

Pre-determine administration timesSpace to enter own times

Date for administration Area when administration is signed for

Check the patient’s name/allergy status first

Written legibly and preferably in block capitals

Clearly indicate times that you want drugs to be

given

- Tick times printed or legibly write times in

yourself

When crossing off medications

- Sign and date every time!

Regular Prescriptions:Key Components Part 2

As Required Prescriptions:

Drug Name

Date of prescription

Dose

Duration of treatment

Route

Signature (AND NAME)

Check the patient’s name/allergy status first

Check regular medication to ensure no

duplication

– E.g. Paracetamol and co-codamol

Write legibly and preferably in block capitals

Use generic drug names not trade names

Dose and route have to legible

Sign and print you name for each prescription

Do not abbreviate micrograms and units

As required prescriptions:Key Components

Re-writing of Drug Charts

Check all drug charts every time you

review your patients

Re-write charts yourselves

– You know the patient

– More time during the day than “out of hours”

Shouldn’t be an “out of hours job”

– Extra work for colleagues

– Increased risk of errors occurring

Summary

Prescribing is a complex process

Make yourself familiar with the drug chart(s)

used where you are working

Take time when prescribing

Try to ensure you minimise the risk of errors

in the prescribing pathway occurring

Know sources of advice and help when you

are prescribing