A prescription (℞) is a health-care program implemented by a physician A physician — also known as medical practitioner, doctor of medicine, medical doctor, or simply doctor — practices the ancient profession of medicine, which is concerned with maintaining or restoring human health through the study, diagnosis, and treatment of disease or injury. This properly requires both a detailed knowledge of the academic or other medical practitioner in the form of instructions that govern the plan of care for an individual patient.^[1] Prescriptions may include orders to be performed by a patient A patient is any person who receives medical attention, care, or treatment. The person is most often ill or injured and in need of treatment by a physician or other health care professional, although one who is visiting a physician for a routine check-up may also be viewed as a patient, caretaker Carer and caregiver (US, Canadian usage) are words normally used to refer to unpaid relatives or friends who support people with disabilities. The words may be prefixed with "family" "spousal", "child" to distinguish between different care situations. The general term dependent/dependant care is also used for the, nurse A nurse is a healthcare professional who, in collaboration with other members of a health care team, is responsible for: treatment, safety, and recovery of acutely or chronically ill individuals; health promotion and maintenance within families, communities and populations; and, treatment of life-threatening emergencies in a wide range of health, pharmacist Pharmacists are health professionals who practice the science of pharmacy. In their traditional role, pharmacists typically take a request for medicines from a prescribing health care provider in the form of a medical prescription, evaluate the appropriateness of the prescription, dispense the medication to the patient and counsel them on the or other therapist Psychotherapy or personal counseling with a psychotherapist, is an intentional interpersonal relationship used by trained psychotherapists to aid a client or patient in problems of living. Commonly, the term prescription is used to mean an order to take certain medications A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease. Prescriptions have legal implications, as they may indicate that the prescriber takes responsibility for the clinical care of the patient and in particular for monitoring efficacy and safety Safety is the state of being "safe" , the condition of being protected against physical, social, spiritual, financial, political, emotional, occupational, psychological, educational or other types or consequences of failure, damage, error, accidents, harm or any other event which could be considered non-desirable. This can take the form. However, as medications have increasingly become pre–packaged manufactured products and medical practice has become more complex, the scope of meaning of the term "prescription" has broadened to also include clinical assessments, laboratory tests, and imaging studies relevant to optimizing the safety or efficacy.

Format and definition

Prescriptions are handwritten Penmanship or handwriting is the art of writing with the hand and a writing instrument. Styles of handwriting are also called hands or scripts on preprinted prescription forms that are assembled into pads, or alternatively printed onto similar forms using a computer printer In computing, a printer is a peripheral which produces a hard copy of documents stored in electronic form, usually on physical print media such as paper or transparencies. Many printers are primarily used as local peripherals, and are attached by a printer cable or, in most newer printers, a USB cable to a computer which serves as a document. Preprinted on the form is text that identifies the document as a prescription, the name and address of the prescribing provider and any other legal requirement such as a registration number (e.g. DEA The Drug Enforcement Administration is a federal law enforcement agency under the United States Department of Justice, tasked with combating drug smuggling and use within the United States. Not only is the DEA the lead agency for domestic enforcement of the drug policy of the United States sharing concurrent jurisdiction with the Federal Bureau of Number in the United States ^ b. English is the de facto language of American government and the sole language spoken at home by 80% of Americans age five and older. Spanish is the second most commonly spoken language). Unique for each prescription is the name of the patient. In the United Kingdom The United Kingdom of Great Britain and Northern Ireland[note 7] is a sovereign state located off the northwestern coast of continental Europe. It is an island country, spanning an archipelago including Great Britain, the northeastern part of Ireland, and many small islands. Northern Ireland is the only part of the UK with a land border, sharing the patient's name and address must also be recorded. Each prescription is dated and some jurisdictions Jurisdiction is the practical authority granted to a formally constituted legal body or to a political leader to deal with and make pronouncements on legal matters and, by implication, to administer justice within a defined area of responsibility may place a time limit on the prescription.^[2] There is the specific "recipe" of the medication and the directions for taking it.

℞ is a symbol meaning "prescription". It is sometimes transliterated From an information-theoretical point of view, transliteration is a mapping from one system of writing into another, word by word, or ideally letter by letter. Transliteration attempts to use a one-to-one correspondence and be exact, so that an informed reader should be able to reconstruct the original spelling of unknown transliterated words. To as "R_x" or just "Rx". There are various theories about the origin of this symbol - some note its similarity to the Eye of Horus The Eye of Horus (previously Wadjet and the Eye of the Moon; and afterwards as The Eye of Ra) or ("Udjat") is an ancient Egyptian symbol of protection and royal power from deities, in this case from Horus or Ra. The symbol is seen on images of Horus' mother, Isis, and on other deities associated with her,^[3][4] others to the ancient symbol for Jupiter Astronomical symbols are symbols used to represent various celestial objects, theoretical constructs and observational events in astronomy. The symbols listed here are commonly used by professional and amateur astronomers.[citation needed] Many of the symbols are shared with western astrology, which uses multiple variant forms, both gods whose protection may have been sought in medical contexts. Alternatively, it may be intended as an abbreviation of the Latin "recipe",^[5] the imperative form of "recipere", "to take or take thus",^[6] and it is quite possible that more than one of these factors influenced its form. Literally, "Recipe" means simply "Take...." and when a medical practitioner writes a prescription beginning with "℞", he or she is completing the command. This was probably originally directed at the pharmacist who needed to take a certain amount of each ingredient to compound the medicine Medicine is the art and science of healing. It encompasses a range of health care practices evolved to maintain and restore health by the prevention and treatment of illness, rather than at the patient who must "take" the medicine, in the sense of consuming it. The word "prescription" can be decomposed into "pre" and "script" and literally means, "to write before" a drug can be prepared. Those within the industry will often call prescriptions simply "scripts". Another theory exists that the "℞" may have originally been a "Px", where the "P" is short for "pre", and the "x" is short for "script".

Contents

Both pharmacists and prescribers are regulated professions in most jurisdictions. A prescription as a communications mechanism between them is also regulated and is a legal document.

Regulations may define what constitutes a prescription, the contents and format of the prescription (including the size of the piece of paper - see Exhibit C paragraph 10) and how prescriptions are handled and stored by the pharmacist. Many jurisdictions will now allow faxed or phone prescriptions containing the same information. Exhibit A below illustrates the legal definition of a prescription.

Many brand name drugs have less expensive generic drug A generic drug is a drug which is produced and distributed without patent protection. The generic drug may still have a patent on the formulation but not on the active ingredient substitutes that are therapeutically equivalent. Prescriptions will also contain instructions on whether the prescriber will allow the pharmacist to substitute a generic version of the drug A drug, broadly speaking, is any substance that, when absorbed into the body of a living organism, alters normal bodily function. There is no single, precise definition, as there are different meanings in drug control law, government regulations, medicine, and colloquial usage. This instruction is communicated in a number of ways.

In some jurisdictions, the preprinted prescription contains two signature lines: one line has "dispense as written" printed underneath; the other line has "substitution permitted" underneath. Some have a preprinted box "dispense as written" for the prescriber to check off (but this is easily checked off by anyone with access to the prescription). Other jurisdictions the protocol is for the prescriber to handwrite one of the following phrases: "dispense as written", "DAW", "brand necessary", "do not substitute", "no substitution", "medically necessary", "do not interchange".^[7] In other jurisdictions may they use completely different languages, never mind a different formula of words. In some jurisdictions, it may be a legal requirement to include the age of child on the prescription.^[8] For pediatric prescriptions some advise the inclusion of the age of the child if the patient is less than twelve and the age and months if less than five. (In general, including the age on the prescription is helpful.) Adding the weight of the child is also helpful.

Prescriptions often have a "label" box.^[9] When checked, the pharmacist is instructed to label the medication. When not checked, the patient only receives instructions for taking the medication and no information about the prescription itself.

Some prescribers further inform the patient and pharmacist by providing the indicator for the medication; i.e. what is being treated. This assists the pharmacist in checking for errors as many common medications can be used for multiple medical conditions.

Some prescriptions will specify whether and how many "repeats" or "refills" are allowed; that is whether the patient may obtain more of the same medication without getting a new prescription from the medical practitioner. Regulations may restrict some types of drugs from being refilled.

In group practices, the preprinted portion of the prescription may contain multiple prescribers' names. Prescribers typically circle themselves to indicate who is prescribing or there may be a checkbox next to their name.

Handling

When filled by a pharmacist, as a matter of business practice, the pharmacist may write certain information right on the prescription. This may also be mandated by legislation (see Exhibit D). Information such as the actual manufacturer of the drug and the date the medication was dispensed may be written right onto the prescription. Legislation may require the pharmacist sign the prescription. In computerized pharmacies, all such information is printed and stapled to the prescription. Sometimes such information is printed onto labels and the labels affixed right onto the prescription.

When filled by the pharmacist, prescriptions are typically assigned a "prescription number" (often abbreviated "Rx#" in the US) that is unique to the pharmacy that filled the prescription. The prescription number is written right on the prescription by the pharmacist. The prescription number has the practical purpose of uniquely identifying the prescription later on while filed (both manual and electronic). The prescription number is also put on the label on the dispensed medication. The patient may be required to reference the prescription number for refills and drug insurance claims. There may also be a legal requirement for prescription numbers for subsequent identification purposes.

As a legal document, some jurisdictions will mandate the archiving of the original paper prescription in the pharmacy. Often the patient cannot take the original prescription with them. Some jurisdictions may entitle patients to a copy. The retention period varies but can be as long as six years. See Exhibit B for sample legislation governing the archiving of prescriptions. Once the retention period has passed, privacy legislation may dictate what can be done with the original paper prescription. Legislation may also dictate what happens to the prescriptions if the pharmacy closes or is sold. For example, if the pharmacy goes out of business, the pharmacist may be required to return the prescription to the patient, to the next closest pharmacy or to the governing body for pharmacists.

Prescriptions for non-narcotic drugs may also be "transferred" from one pharmacy to another for subsequent repeats to be dispensed from another pharmacy. The physical piece of paper that is the prescription is not transferred, but all the information on it is transferred from one pharmacy to another. Legislation may dictate the protocol by which the transfer occurs and whether the transfer needs to be noted on the original paper prescription.

It is estimated that three billion 1,000,000,000 is the natural number following 999,999,999 and preceding 1,000,000,001 (three thousand million) prescriptions were written in the United States in 2002.^[10] This number grew from 1.5 billion in 1989 and is expected to continue to grow.

Forgeries and prevention

Prescriptions are sometimes forged because many narcotics It is believed to have been coined by the Greek physician Galen to refer to agents that numb or deaden, causing loss of feeling or paralysis. It is based on the Greek word ναρκωσις , the term used by Hippocrates for the process of numbing or the numbed state. Galen listed mandrake root, altercus (eclata) seeds, and poppy juice (opium) as are cheaper and safer as prescription drugs than as street drugs. Forgery takes many forms: Prescription pads are sometimes stolen, amounts may be altered on legitimate prescriptions, call back numbers may be falsified and phoned or faxed prescriptions faked.^[11]

Some medical practitioners will use prescription pads that contain similar security measures as checks to make photocopying prescriptions harder. These security measures may be mandated by law—see Exhibit C for sample legal specifications. Legislation may mandate that only certain printers may print prescriptions.^[12] New Jersey, for example, requires that only state approved printers may be used to print official "New Jersey Prescription Blanks."^[13] (See Exhibit E.) Prescribers can make it harder for amount forgeries by writing out the amounts in words. Again, this may be mandated by law.^[14]

Some jurisdictions help control stolen prescriptions by requiring special "triplicate prescriptions" for certain classes of drugs.^[15] Blank triplicates are only available from the regulating agency and are individually numbered. The medical practitioner retains a copy, the second and third copies are given to the patient to give to the pharmacist. The pharmacist retains the second copy and the third copy is submitted to the regulating agency. The regulating agency can issue lists of forged prescriptions that pharmacists can check. In this example, the prescription's validity is further limited to 72 hours from issuance. California California (pronounced /kælɨˈfɔrnjə/ ) is the most populous state in the United States, and the third largest by area. California is the second most populous sub-national entity in the Americas, behind only São Paulo, Brazil. It is located on the West Coast of the United States, and is bordered by Oregon to the north, Nevada to the northeast, has recently replaced triplicate forms with new forms that are impossible to photocopy or fax: the background is printed with repetitions of the word void in a color that shows up as black on a photocopy.

States have various laws making theft of prescription blanks or forgery of prescriptions criminal offenses and/or providing special treatment for these offenses (for Example N.J. Stat. 2C:21-1. making forgery of a prescription blank a third degree rather than fourth degree offense).^[16]

When forgery is suspected, pharmacists will call the medical practitioner to verify the prescription. Forged prescriptions are no longer considered medical documents and doctor-patient confidentiality rules no longer apply.

Writing prescriptions

Who can write prescriptions

Who can issue prescriptions is governed by local legislation. In the United States medical practitioners, veterinarians A veterinarian or a veterinary surgeon (British English), often shortened to vet, is a physician for animals and a practitioner of veterinary medicine. The word comes from the Latin veterinae meaning "working animals". "Veterinarian" was first used in print by Thomas Browne in 1646, dentists Dentistry is the known evaluation, diagnosis, prevention, and treatment of diseases, disorders and conditions of the soft and hard tissues of the jaw , the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is a part of stomatology. Dentistry is widely considered necessary for, and podiatrists Podiatry is a branch of health care devoted to the study, diagnosis and treatment of disorders of the foot, ankle and lower leg have prescribing power. In addition, clinical pharmacists Clinical pharmacy is the branch of Pharmacy where pharmacists and pharmaconomists provide patient care that optimizes the use of medication and promotes health, wellness and disease prevention. Clinical pharmacists and clinical pharmaconomists care for patients in all health care settings but the clinical pharmacy movement initially began inside are allowed to prescribe in some states through the use of a drug formulary or collaboration agreements. In all states, optometrists Optometry is a health care profession concerned with eyes and related structures, as well as vision, visual systems, and vision information processing in humans prescribe medications to treat certain eye diseases, and also issue spectacle and contact lens prescriptions An eyeglass prescription is a written order by an optometrist or ophthalmologist. It specifies the refractive power to which each lens should be made in order to correct blurred vision due to refractive errors, including myopia, hyperopia, astigmatism, and presbyopia. It is typically determined using a phoropter asking the patient which lens is for corrective eyewear.^[17] States allow registered certified physician assistants A physician assistant is a healthcare professional licensed to practice medicine with supervision of a licensed physician. A physician assistant is concerned with preventing, maintaining, and treating human illness and injury by providing a broad range of health care services that are traditionally performed by a physician. Physician assistants (also known as physician associates or PAs) prescription powers in all 50 states. Several states have passed RxP The Prescriptive authority for psychologists movement is a political effort to give prescriptive authority to clinical psychologists, enabling them to prescribe psychotropic medications to treat mental and emotional disorders. Prior to RxP legislation and in states where it has not been passed, this role is played by psychiatrists, who possess a legislation, allowing clinical psychologists (PhD's or PsyD's) who are registered as medical psychologists and have also undergone specialized training in script-writing to prescribe a limited number of drugs to treat emotional and mental disorders. Nurse practitioners A Nurse Practitioner is a registered nurse who has completed specific advanced nursing education (generally a master's degree or doctoral degree) and training in the diagnosis and management of common as well as a few complex medical conditions. Nurse Practitioners are generally licensed through nursing boards rather than medical boards. Nurse are authorized to write prescriptions in some states^[18][19] Florida Pharmacists can write prescriptions for a limited set of drugs.^[20]

Legibility

Prescriptions, when handwritten, are notorious for being often illegible. In the US, medical practitioners' sloppy handwriting kills more than 7,000 people annually, according to a July 2006 report from the National Academies of Science's Institute of Medicine (IOM).^[21] Historically, physicians used Latin words and abbreviations to convey the entire prescription to the pharmacist. Today, many of the abbreviations are still widely used and must be understood to interpret prescriptions. At other times, even though some of the individual letters are illegible, the position of the legible letters and length of the word is sufficient to distinguish the medication based on the knowledge of the pharmacist. When in doubt, pharmacists call the medical practitioner. Some jurisdictions have legislated legible prescriptions (e.g. Florida).^[22] Some have advocated the elimination of handwritten prescriptions altogether^[23] and computer printed In computing, a printer is a peripheral which produces a hard copy of documents stored in electronic form, usually on physical print media such as paper or transparencies. Many printers are primarily used as local peripherals, and are attached by a printer cable or, in most newer printers, a USB cable to a computer which serves as a document prescriptions are becoming increasingly common in some places.

Conventions for avoiding ambiguity

Over the years, prescribers have developed many conventions for prescription-writing, with the goal of avoiding ambiguities or misinterpretation.^[24][25][26] These include:

• Careful use of decimal points to avoid ambiguity:
  • Avoiding unnecessary decimal points: a prescription will be written as 5 mL instead of 5.0 mL to avoid possible misinterpretation of 5.0 as 50.
  • Always using zero prefix decimals: e.g. 0.5 instead of .5 to avoid misinterpretation of .5 as 5.
  • Avoiding trailing zeros on decimals: e.g. 0.5 instead of .50 to avoid misinterpretation of .50 as 50.
  • Avoiding decimals altogether by changing the units: 0.5 g is less easily confused when written as 500 mg.
• "mL The litre is a unit of volume. There are two official symbols: the Latin letter L in lower and upper case (l and L). The lower case L is also often written as a cursive ℓ, though this symbol has no official approval by any international bureau. Although the litre is not an SI unit, it is accepted for use with the SI, and has appeared in several" is used instead of "cc A cubic centimetre or cubic centimeter is a commonly used unit of volume extending the derived SI-unit cubic metre and corresponds to the volume of a cube measuring 1×1×1 cm. One cubic centimetre corresponds to a volume of 1⁄1,000,000 of a cubic metre, or 1⁄1000 of a litre, or one millilitre; thus, 1 cm3 ≡ 1 mL. The mass of one cubic" or "cm³" even though they are technically equivalent to avoid misinterpretation of 'c' as '0' or the common medical abbreviation for "with" (the Latin "cum"), which is written as a 'c' with a bar above the letter. Further, cc could be misinterpreted as "c.c.", which is an uncommonly used abbreviation for "take with meals" (the Latin "cum cibum").
• Directions written out in full in English (although some common Latin abbreviations are listed below).
• Quantities given directly or implied by the frequency and duration of the directions.
• Where the directions are "as needed", the quantity should always be specified.
• Where possible, usage directions should specify times (7 am, 3 pm, 11 pm) rather than simply frequency (three times a day) and especially relationship to meals for orally consumed medication.
• The use of permanent ink.
• Avoiding unspecified prn Pro re nata is a Latin phrase that literally means "for the thing born". It is commonly used in medicine to mean "as needed" or "as the situation arises." It is generally used as the acronym PRN to refer to dosage of prescribed medication that is not scheduled; instead administration is left to the caregiver or the or "as needed" instructions—instead, specific limits and indicators are provided e.g. "every 3 hours prn pain."
• For refills, the minimum duration between repeats and number of repeats should be specified.
• Providing the indication for all prescriptions even when obvious to the prescriber, so that the pharmacist may identify possible errors.
• Avoiding units such as "teaspoons" or "tablespoons."
• Writing out numbers as words and numerals ("dispense #30 (thirty)") as in a bank draft A cashier's check is a check guaranteed by a bank. They are usually treated as cash since most banks clear them instantly. However, banks are permitted to take back money from a "cleared" check one or two weeks later if subsequent processing finds it to be fraudulent. Because customers believe the checks have been found valid and have or cheque A cheque or check is a negotiable instrument[nb 1] instructing a financial institution to pay a specific amount of a specific currency from a specified demand account held in the maker/depositor's name with that institution. Both the maker and payee may be natural persons or legal entities.
• The use of apothecary Apothecary is a historical name for a medical professional who formulates and dispenses materia medica to physicians, surgeons and patients — a role now served by a pharmacist (or, especially in British English, a chemist or dispensing chemist)/avoirdupois The avoirdupois system is a system of weights (or, properly, mass) based on a pound of sixteen ounces. It is the everyday system of weight used in the United States, and is still widely used to varying degrees by many people in Canada, the United Kingdom, and some other former British colonies despite the official adoption of the metric system units and symbols of measure -- pints The pint is an English unit of volume or capacity in the imperial system and United States customary units. The imperial version is 20 imperial fluid ounces and is equivalent to about 568 ml, while the U.S. version is 16 U.S. fluid ounces and is equivalent to about 473 ml. Pints are commonly abbreviated as either "p" or "pt" (O), ounces The ounce is a unit of weight with several definitions, the most commonly used of which are equal to approximately 28 grams. The ounce is used in a number of different systems, including various systems of mass that form part of the imperial and United States customary systems. Its size can vary from system to system. The most commonly used ounces (℥), drams The dram was historically both a coin and a weight. Currently it is both a small mass in the Apothecaries' system of weights and a small unit of volume. This unit is called more correctly fluid dram or in contraction also fluidram (ℨ), scruples (℈), grains A grain is a unit of measurement of mass that is based upon the mass of a single seed of a typical cereal. Historically, in Europe, the average masses of wheat and barley grain were used to define units of mass, with the troy grain based on barley. Since 1958, the grain or troy grain measure has been redefined on the basis of the unit of mass of (gr), and minims (♏) -- is discouraged given the potential for confusion. For example, the abbreviation for a grain ("gr") can be confused with the gram The gram , (Greek/Latin root grámma); symbol g, is a unit of mass, abbreviated g The gram , (Greek/Latin root grámma); symbol g, is a unit of mass, and the symbol for minims (♏), which looks almost identical to an 'm', can be confused with micrograms In the metric system, a microgram is 1/1,000,000 of a gram (1 × 10–6), or 1/1000 of a milligram, is one of the smallest units of weight/mass commonly used. The abbreviation μg is often used in scientific literature, but JCAHO recommends that hospitals do not use this abbreviation in handwritten orders due to the risk that the Greek letter μ or meters The metre is the basic unit of length in the International System of Units (SI). Historically, the metre was defined by the French Academy of Sciences as the length between two marks on a platinum-iridium bar, which was designed to represent one ten-millionth of the distance from the Equator to the North Pole along Paris Meridian (compare: Geoid). Also, the symbols for ounce (℥) and dram (ℨ) can easily be confused with the numeral '3', and the symbol for pint (O) can be easily read as a '0'. Given the potential for errors, metric The metric system is an international decimalised system of measurement, first adopted by France in 1791, that is the common system of measuring units used by most of the world. It exists in several variations, with different choices of fundamental units, though the choice of base units does not affect its day-to-day use. Over the last two equivalents should always be used.
• The use of the degree symbol (°), which is commonly used as an abbreviation for hours (e.g., "q 2-4°" for every 2 - 4 hours), should not be used, since it can be confused with a '0'. Further, the use of the degree symbol for primary, secondary, and tertiary (1°, 2°, and 3°) is discouraged, since the former could be confused with quantities (i.e. 10, 20 and 30, respectively).

Abbreviations

See list of abbreviations used in medical prescriptions. Many abbreviations are derived from Latin phrases. Hospital pharmacies have more abbreviations, some specific to the hospital. Different jurisdictions follow different conventions on what is abbreviated or not. Prescriptions that don't follow area conventions may be flagged as possible forgeries.

Some abbreviations which are ambiguous, or which in their written form might be confused with something else, are not recommended and should be avoided. These are included in a separate list in Appendix 1. However, all abbreviations carry an increased risk for confusion and misinterpretation and should be used cautiously.

Non-prescription drug prescriptions

Prescriptions are also used for things that are not strictly regulated as a prescription drug. Prescribers will often give non-prescription drugs out as prescriptions because drug benefit plans may reimburse the patient only if the over-the-counter medication is taken under the direction of a medical practitioner. Conversely, if a medication is available over-the-counter, prescribers may ask patients if they want it as a prescription or purchase it themselves. Pharmacists may or may not be able to price the medication competively with over-the-counter equivalents. If the patient wants the medication not under prescription, the prescriber is usually careful to give the medication name to the patient on a blank piece of paper to avoid any confusion with a prescription. This is applied to non-medications as well. For example, crutches, and registered massage therapy may be reimbursed under some health plans, but only if given out by a prescriber as a prescription.

Prescribers will often use blank prescriptions as general letterhead. Legislation may define certain equipment as "prescription devices".^[27] Such prescription devices can only be used under the supervision of authorized personnel and such authorization is typically documented using a prescription. Examples of prescription devices include dental cement (for affixing braces to tooth surfaces), various prostheses, gut sutures, sickle cell tests, cervical cap and ultrasound monitor.

In some jurisdictions, hypodermic syringes are in a special class of their own, regulated as illicit drug use accessories^[28] separate from regular medical legislation. Such legislation will often specify a prescription as the means by which one may legally possess syringes.

Related usage of the term prescription

Prescription may also be used as a short form for prescription drugs to distinguish from over-the-counter drugs. In reference to the entire system of controlling drug distribution (as opposed to illicit drugs), "prescription" is often used as a metaphor for healthy directions from a prescribing medical practitioner. A "green prescription" is direction from a medical practitioner to a patient for exercise and healthy diet.

History

The concept of prescriptions dates back to the beginning of history. So long as there were medications and a writing system to capture directions for preparation and usage, there were prescriptions.^[29]

Modern prescriptions are actually "extemporaneous prescriptions" from the Latin (ex tempore) for "at/from time".^[30] "Extemporaneous" means the prescription is written on the spot for a specific patient with a specific ailment. This is distinguished from a non-extemporaneous prescription which is a generic recipe for a general ailment. Modern prescriptions evolved with the separation of the role of the pharmacists from that of the physician.^[31] Today the term "extemporaneous prescriptions" is reserved for "compound prescriptions" which requires the pharmacist to mix or "compound" the medication in the pharmacy for the specific needs of the patient.

Predating modern legal definitions of a prescription, a prescription traditionally is composed of four parts: a "superscription", "inscription", "subscription" and "signature".^[32]

The superscription section contains the date of the prescription and patient information (name, address, age, etc). The symbol "℞" separates the superscription from the inscriptions sections. In this arrangement of the prescription, the "℞" is a symbol for recipe or literally the imperative "take." This is an exhortation to the pharmacist by the medical practitioner, "I want the patient to have the following medication"^[33] - in other words, "take the following components and compound this medication for the patient."

The inscription section defines what is the medication. The inscription section is further composed of one or more of:^[34]

• a "basis" or chief ingredient indended to cure (curare)
• an "adjuvant" to assist its action and make it cure quickly (cito)
• a "corrective" to prevent or lessen any undesirable effect (tuto)
• a "vehicle" or "excipient" to make it suitable for administration and pleasant to the patient (jucunde)

The "subscription" section contains dispensing directions to the pharmacist. This may be compounding instructions or quantities.

The "signature" section contains directions to the patient^[35] and is often abbreviated "Sig."^[36] or "Signa." It also obviously contains the signature of the prescribing medical practitioner though the word "signature" has two distinct meanings here and the abbreviations are sometimes used to avoid confusion.

Thus sample prescriptions in modern textbooks are often presented as:

℞: medication
Disp.: dispensing instructions
Sig.: patient instructions

Use of Technology

As a prescription is nothing more than information among a prescriber, pharmacist and patient, information technology can be applied to it. Existing information technology is adequate to print out prescriptions. Medical information systems in some hospitals do away with prescriptions within the hospital. There are proposals to securely transmit the prescription from the prescriber to the pharmacist using smartcard or the internet.^[37] In the United Kingdom a project called the Electronic Transfer of Prescriptions (ETP) within the National Programme for IT (NPfIT) is currently piloting such a scheme between prescribers and pharmacies.

Within computerized pharmacies, the information on paper prescriptions is recorded into a database. Afterward, the paper prescription is archived for storage and legal reasons.

A pharmacy chain is often linked together through corporate headquarters with computer networking. Walgreens, for example, uses satellite technology to share patient information. A person who has a prescription filled at one Walgreens can get a refill of that prescription at any other store in the chain, as well as have their information available for new prescriptions at any Walgreens.

Some online pharmacies also offer services to customers over the internet. Walgreens' web site, for example, allows customers to order refills for medicine over the internet, and allows them to specify the store that they will pick up the medicine from. Their web site also allows consumers to lookup their prescription history, and to print it out.

Many pharmacies now offer services to ship prescription refills right to the patient's home. CVS, for example, will ship refills free of charge. They also offer mail service where you can mail in a new, original prescription and a signed document, and they will ship the filled prescription back to you.

Pharmacy information systems are a potential source of valuable information for pharmaceutical companies as it contains information about the prescriber's prescribing habits. Prescription data mining of such data is a developing, specialized field.^[38]

Many prescribers lack the digitized information systems that reduce prescribing errors.^[39] To reduce these errors, some investigators have developed modified prescription forms that prompt the prescriber to provide all the desired elements of a good prescription. The modified forms also contain pre-defined choices such as common quantities, units and frequencies that the prescriber may circle rather than write out. Such forms are thought to reduce errors, especially omission and handwriting errors and are actively under evaluation. (See: Kennedy AG, Littenberg B. A Modified Outpatient Prescription Form to Reduce Prescription Errors. Joint Commission Journal of Quality and Safety 2004; 30:480-487.)

Exhibit A: sample legal definition of a prescription

Taken from California's Business and Professions Code Section 4040: ^[40]

4040. (a) "Prescription" means an oral, written, or electronic transmission order that is both of the following:

(1) Given individually for the person or persons for whom ordered that includes all of the following:

(A) The name or names and address of the patient or patients.

(B) The name and quantity of the drug or device prescribed and the directions for use.

(C) The date of issue.

(D) Either rubber stamped, typed, or printed by hand or typeset, the name, address, and telephone number of the prescriber, his or her license classification, and his or her federal registry number, if a controlled substance is prescribed.

(E) A legible, clear notice of the condition for which the drug is being prescribed, if requested by the patient or patients.

(F) If in writing, signed by the prescriber issuing the order, or the certified nurse-midwife, nurse practitioner, or physician assistant who issues a drug order pursuant to Section 2746.51,2836.1, or 3502.1.

(2) Issued by a precribing medical practitioner if a drug order is issued pursuant to Section 2746.51, 2836.1, or 3502.1.

(b) Notwithstanding subdivision (a), a written order of the prescriber for a dangerous drug, except for any Schedule II controlled substance, that contains at least the name and signature of the prescriber, the name and address of the patient in a manner consistent with paragraph (3) of subdivision (b) of Section 11164 of the Health and Safety Code, the name and quantity of the drug prescribed, directions for use, and the date of issue may be treated as a prescription by the dispensing pharmacist as long as any additional information required by subdivision (a) is readily retrievable in the pharmacy. In the event of a conflict between this subdivision and Section 11164 of the Health and Safety Code, Section 11164 of the Health and Safety Code shall prevail.

(c) "Electronic transmission prescription" includes both image and data prescriptions. "Electronic image transmission prescription" means any prescription order for which a facsimile of the order is received by a pharmacy from a licensed prescriber. "Electronic data transmission prescription" means any prescription order, other than an electronic image transmission prescription, that is electronically transmitted from a licensed prescriber to a pharmacy.

(d) The use of commonly used abbreviations shall not invalidate an otherwise valid prescription.

(e) Nothing in the amendments made to this section (formerly Section 4036) at the 1969 Regular Session of the Legislature shall be construed as expanding or limiting the right that a chiropractor, while acting within the scope of his or her license, may have to prescribe a device.

Exhibit B: sample legal requirement for storage of prescriptions

From the Mississippi Board of Pharmacy:^[41]

ARTICLE XIII PRESCRIPTIONS TO BE FILED

1. All prescriptions shall be filed in one of the following ways:

A. Three separate files may be maintained; a file for Schedule II prescriptions dispensed; a file for Schedule III, IV and V prescriptions dispensed; and a file for all other prescriptions dispensed.

B. Two files may be maintained; a file for all Schedule II prescriptions dispensed and another file for all other prescriptions dispensed, including those in Schedule III, IV and V. If this method is used, the prescriptions for Schedule III, IV and V substances must be stamped with the letter "C" in red ink, not less than one inch high, in the lower right-hand corner. This distinctive marking makes the records readily retrievable for inspection. Pharmacies with automatic data processing systems are exempted from marking Schedule III, IV and V controlled substance prescriptions with the red "C".

2. A hard copy of original prescriptions, whether records are maintained manually or in a data processing system, shall be assigned a serial number and maintained by the pharmacy in numerical and chronological order. All prescriptions shall be maintained for at least five years from the date of original dispensing.

3. If a pharmacy utilizes a data processing system for record keeping, all computer generated labels should be affixed to the prescription document in such a manner as not to obscure information on the face of the document.

Exhibit C: sample legal requirements for security and format

From Indiana Board of Pharmacy:^[42]

856 IAC 1-34-2 Security feature requirements

Authority: IC 35-48-7-8

Affected: IC 16-42-19-5

Sec. 2. (a) All controlled substance prescriptions written by licensed Indiana practitioners, as defined by IC 16-42-19-5, must contain the following security features:

(1) A latent, repetitive "void" pattern screened at five percent (5%) in reflex blue must appear across the entire face of the document when the prescription is photocopied.

(2) There shall be a custom artificial watermark printed on the back side of the base paper so that it may only be seen at a forty-five (45) degree angle. The watermark shall consist of the words "Indiana Security Prescription", appearing horizontally in a step-and-repeated format in five lines on the back of the document using 12-point Helvetica bold type style.

(3) An opaque RX symbol must appear in the upper right-hand corner, one-eighth (1/8) of an inch from the top of the pad and five-sixteenths (5/16) of an inch from the right side of the pad. The symbol must be three-fourths (3/4) inch in size and must disappear if the prescription copy is lightened.

(4) Six (6) quantity check-off boxes must be printed on the form and the following quantities must appear and the appropriate box be checked off for the prescription to be valid:

(A) 1-24

(B) 25-49

(C) 50-74

(D) 75-100

(E) 101-150

(F) 151 and over.

(5) No advertisements may appear on the front or back of the prescription blank.

(6) Logos, defined as a symbol utilized by an individual, professional practice, professional association, or hospital, may appear on the prescription blank. The upper left one (1) inch square of the prescription blank is reserved for the purpose of logos. Only logos, as defined by this subdivision, may appear on the prescription blank.

(7) Only one (1) prescription may be written per prescription blank. The following statement must be printed on the bottom of the pad: "Prescription is void if more than one (1) prescription is written per blank.".

(8) Refill options that can be circled by the prescriber must appear below any logos and above the signature lines on the left side of the prescription blank in the following order: Refill NR 1 2 3 4 5 Void after_____.

(9) Practitioner name and state issued professional license number must be preprinted, stamped, or manually printed on the prescription.

(10) All prescription blanks printed under this rule shall be four and one-fourth (4-1/4) inches high and five and one-half (5-1/2) inches wide.

(b) Nothing in this rule shall prevent licensed Indiana practitioners from utilizing security paper prescriptions for the prescribing of any legend drug. (Indiana Board of Pharmacy; 856 IAC 1-34-2; filed Jul 5, 1995, 9:45 a.m.: 18 IR 2782, eff Jan 1, 1996)

Exhibit D: sample requirements on information added by the pharmacist

Taken from the Ontario's Drug and Pharmacies Regulation Act, ^[43] paragraph 156.

(1) Every person who dispenses a drug pursuant to a prescription shall ensure that the following information is recorded on the prescription,

(a) the name and address of the person for whom the drug is prescribed;

(b) the name, strength (where applicable) and quantity of the prescribed drug;

(c) the directions for use, as prescribed;

(d) the name and address of the prescriber;

(e) the identity of the manufacturer of the drug dispensed;

(f) an identification number or other designation;

(g) the signature of the person dispensing the drug and, where different, also the signature of the person receiving a verbal prescription;

(h) the date on which the drug is dispensed;

(i) the price charged. R.S.O. 1990, c. H.4, s. 156 (1).

Exhibit E: New Jersey requirements for prescription blanks

From New Jersey official statutes:^[44]

45:14-55 Use of New Jersey Prescription Blanks.

16. a. A practitioner practicing in this State shall use non-reproducible, non-erasable safety paper New Jersey Prescription Blanks bearing that practitioner's license number whenever the practitioner issues prescriptions for controlled dangerous substances, prescription legend drugs or other prescription items. The prescription blanks shall be secured from a vendor approved by the Division of Consumer Affairs in the Department of Law and Public Safety.

b. A licensed practitioner practicing in this State shall maintain a record of the receipt of New Jersey Prescription Blanks. The practitioner shall notify the Office of Drug Control in the Division of Consumer Affairs as soon as possible but no later than 72 hours of being made aware that any New Jersey Prescription Blank in the practitioner's possession has been stolen. Upon receipt of notification, the Office of Drug Control shall take appropriate action, including notification to the Department of Human Services and the Attorney General.

45:14-56 Health care facility prescriptions.

17. a. Prescriptions issued by a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall be written on non-reproducible, non-erasable safety paper New Jersey Prescription Blanks. The prescription blanks shall be secured from a vendor approved by the Division of Consumer Affairs in the Department of Law and Public Safety. The New Jersey Prescription Blanks shall bear the unique provider number assigned to that health care facility for the issuing of prescriptions for controlled dangerous substances, prescription legend drugs or other prescription items.

b. A health care facility shall maintain a record of the receipt of New Jersey Prescription Blanks. The health care facility shall notify the Office of Drug Control in the Division of Consumer Affairs as soon as possible but no later than 72 hours of being made aware that any New Jersey Prescription Blank in the facility's possession has been stolen. Upon receipt of notification, the Office of Drug Control shall take appropriate action including notification to the Department of Human Services and the Attorney General.

45:14-57 Requirements for prescription to be filled.

18.A prescription issued by a practitioner or health care facility licensed in New Jersey shall not be filled by a pharmacist unless the prescription is issued on a New Jersey Prescription Blank bearing the practitioner's license number or the unique provider number assigned to a health care facility.

45:14-59 Format for New Jersey Prescription Blanks.

20.The Division of Consumer Affairs in the Department of Law and Public Safety shall establish the format for uniform, non-reproducible, non-erasable safety paper prescription blanks, to be known as New Jersey Prescription Blanks, which format shall include an identifiable logo or symbol that will appear on all prescription blanks. The division shall approve a sufficient number of vendors to ensure production of an adequate supply of New Jersey Prescription Blanks for practitioners and health care facilities statewide.

See also

• Eyeglass prescription
• List of abbreviations used in medical prescriptions
• Off-label use
• Prescription drugs
• Private prescription

Notes

1. ^ Belknap 2008
2. ^ [1]
3. ^ Eye of Horus, Eye of Ra (Udjat, Wedjat)
4. ^ First recorded incidence of the pharmaceutical sign '℞'
5. ^ Amy Beth Dukoff. "Did You Know Where Rx Came From?". Endomail.com. http://www.endomail.com/articles/ad13rx.html. Retrieved 2010-01-22.
6. ^ "Recipe definition". M-w.com. 2007-04-25. http://www.m-w.com/cgi-bin/dictionary?book=Dictionary&va=recipe. Retrieved 2010-01-22.
7. ^ "State Laws or Statutes Governing Generic Substitution by Pharmacists". : Epilepsy.com/Professionals. 2007-04-25. http://professionals.epilepsy.com/page/statutes_by_pharmacists.html. Retrieved 2010-01-22.
8. ^ [2]^{[broken citation]}
9. ^ Davis, T (August 30, 2005). "Prescription Writing and the PDR". Comprehensive Care Clinic. http://www.sh.lsuhsc.edu/fammed/OutpatientManual/PrescripWriting-PDR.htm. Retrieved 2010-01-22.
10. ^ "What lurks in your medicine cabinet?". USA Weekend. 2002-12-01. http://www.usaweekend.com/02_issues/021201/021201healthsmart.html.
11. ^ "A Pharmacist's Guide to Prescription Fraud". US DOJ Drug Enforcement Administration Office of Diversion Control. February 2000. http://www.deadiversion.usdoj.gov/pubs/brochures/pharmguide.htm.
12. ^ [3]
13. ^ [4]
14. ^ [5]
15. ^ CPSA Triplicate Prescription Program
16. ^ "An Act concerning forgery and amending N.J.S.2C:21-1 and supplementing Title 2C of the New Jersey Statutes". http://www.njleg.state.nj.us/2000/Bills/PL01/110_.HTM. Retrieved 2010-01-22.
17. ^ [6]
18. ^ "US Nurse Practitioner Prescribing Law: A State-by-State Summary". Medscape. December 14, 2009. http://www.medscape.com/viewarticle/440315.
19. ^ Batey MV, Holland JM (March 1985). "Prescribing practices among nurse practitioners in adult and family health" (PDF). American Journal of Public Health 75 (3): 258–62. PMID 3976950. PMC 1646172. http://ajph.aphapublications.org/cgi/reprint/75/3/258.pdf. Retrieved 2010-01-22.
20. ^ "Florida's Pharmacists Can Write Prescriptions". The New York Times. May 2, 1986. http://www.nytimes.com/1986/05/02/us/around-the-nation-florida-s-pharmacists-can-write-prescriptions.html. Retrieved 2010-01-22.
21. ^ Caplan, Jeremy (2007-01-15). "Cause of Death: Sloppy Doctors". Time. http://www.time.com/time/health/article/0,8599,1578074,00.html. Retrieved 2010-01-22.
22. ^ "456.42 Written prescriptions for medicinal drugs". Florida Statutes. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0456/SEC42.HTM&Title=-%3E2008-%3ECh0456-%3ESection%2042.
23. ^ "Eliminate Handwritten Prescriptions Within 3 Years". Institute for Safe Medication Practices. 1999-12-07. http://www.ismp.org/msaarticles/whitepaper.html. Retrieved 2010-01-22.
24. ^ [7]^{[broken citation]}
25. ^ [8]
26. ^ Teichman PG, Caffee AE (2002). "Prescription writing to maximize patient safety" (PDF). Family Practice Management 9 (7): 27–30. PMID 12221761. http://www.aafp.org/fpm/2002/0700/p27.pdf. Retrieved 2010-01-22.
27. ^ "CFR - Code of Federal Regulations Title 21". U.S. Food and Drug Administration (FDA). 2009-04-01. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?FR=801.109. Retrieved 2010-01-22.
28. ^ "(720 ILCS 635/) Hypodermic Syringes and Needles Act". Illinois Compiled Statutes. http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1954&ChapAct=720%26nbsp%3BILCS%26nbsp%3B635%2F&ChapterID=53&ChapterName=CRIMINAL+OFFENSES&ActName=Hypodermic+Syringes+and+Needles+Act%2E.
29. ^ "Pharmacy in Ancient Babylonia". History of Pharmacy. Washington State University College of Pharmacy. http://www.pharmacy.wsu.edu/History/history02.html. Retrieved 2010-01-22.
30. ^ "Extemporaneous definition". M-w.com. 2007-04-25. http://www.m-w.com/cgi-bin/dictionary?book=Dictionary&va=extemporaneous. Retrieved 2010-01-22.
31. ^ [9]
32. ^ Potter, Samuel O.L. (1902). "Prescription Writing". A Compend of Materia Medica, Therapeutics, and Prescription Writing (sixth ed.). P. BLAKISTON'S SON. http://www.henriettesherbal.com/eclectic/potter-comp/prescription.html. Retrieved 2010-01-22.
33. ^ [10]
34. ^ "Therapeutics". LoveToKnow Free Online Encyclopedia. 2006-02-15. http://www.1911encyclopedia.org/Therapeutics. Retrieved 2010-01-22.
35. ^ "Signature definition". M-w.com. 2007-04-25. http://www.m-w.com/cgi-bin/dictionary?book=Dictionary&va=signature. Retrieved 2010-01-22.
36. ^ [11]
37. ^ "IEEE Computer Society Conference Publishing Services". http://www.computer.org/proceedings/hicss/1435/volume6/14350156babs.htm.
38. ^ Zoutman DE, Ford BD, Bassili AR (October 2000). "A call for the regulation of prescription data mining". Canadian Medical Association Journal 163 (9): 1146–8. PMID 11079059. PMC 80247. http://epe.lac-bac.gc.ca/100/201/300/cdn_medical_association/cmaj/vol-163/issue-9/1146.htm. Retrieved 2010-01-22.
39. ^ Zwarenstein 2007
40. ^ "Business And Professions Code Section 4015-4045". California Law. http://www.leginfo.ca.gov/cgi-bin/displaycode?section=bpc&group=04001-05000&file=4015-4045.
41. ^ [12]
42. ^ "Title 856 Indiana Board Of Pharmacy". http://www.state.in.us/legislative/register/Vol24/12Sep/08Q856010150.pdf.
43. ^ [13]
44. ^ "New Jersey Board of Pharmacy Laws". http://www.state.nj.us/lps/ca/laws/pharmlaws.pdf. Retrieved 2010-01-22.

References

• Belknap SM, Moore H, Lanzotti SA, Yarnold PR, Getz M, Deitrick DL, Peterson A, Akeson J, Maurer T, Soltysik RC, Storm GA, Brooks I (September 2008). "Application of software design principles and debugging methods to an analgesia prescription reduces risk of severe injury from medical use of opioids". Clinical Pharmacology & Therapeutics 84 (3): 385–92. doi:10.1038/clpt.2008.24. PMID 18388884.
• Zwarenstein MF, Dainty KN, Quan S, Kiss A, Adhikari NK (October 2007). "A cluster randomized trial evaluating electronic prescribing in an ambulatory care setting". Trials 8: 28. doi:10.1186/1745-6215-8-28. PMID 17915028. PMC 2092426. http://www.trialsjournal.com/content/8/1/28. Retrieved 2010-01-22.

Categories: Pharmacology | Healthcare law | Patient safety

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