A prescription leaves your room and is read by someone who cannot ask you what you meant. The pharmacist has the sheet and nothing else. Most dispensing errors that start in a clinic start there — not in the choice of drug, but in a sheet that left something out.
The letterhead
This part is identical on every sheet you ever issue, which is exactly why it is worth setting up once and never thinking about again.
- Clinic or hospital name, with the address and a phone number that is answered
- Your name and qualification, as they appear on your registration
- Your registration number and the council that issued it
- Your signature
The patient
Name, age and sex, and the date. Age matters more than it looks: it is the one field that lets a pharmacist notice that a dose belongs to an adult and the patient in front of them is nine.
The medicines
Every line needs four things, and a line missing any of them is a question the pharmacist has to guess the answer to.
- The drug, with its strength — "Amoxicillin 500 mg", not "Amoxicillin"
- How much, and in what form
- How often — 1-0-1 and 1-1-1 are read the same way everywhere, which is their whole advantage
- For how long — a duration, not "continue"
Then anything that is not obvious from the four: before or after food, what to stop if a side effect appears, what to do if a dose is missed. Written down, these survive the walk home. Said aloud, they usually do not.
What comes next
If the patient should be seen again, the date belongs on the sheet. A follow-up that exists only as "come back in a week" is a follow-up that depends on the patient remembering the week.
None of this is difficult. It is just long, and it is the same every time — which is the kind of work that should be handled by the letterhead rather than by you, at the end of a day with thirty patients in it.