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Writing the prescription and informing the patient
1Department of Clinical Pharmacology, Royal Adelaide Hospital, Department of Clinical Pharmacology, University of Adelaide, South Australia. sshakib@mail.rah.sa.gov.au
Background:
Having decided on the generic drug to prescribe the prescription needs to be written and the patient informed regarding the treatment.
Objective:
This article discusses some regulatory requirements for writing a legal prescription, but predominantly discusses important aspects of informing patients regarding drug therapy.
Discussion:
The actual writing of a prescription is a small part of the prescribing process and needs to comply with local regulations. Including patients in the decision to embark on a treatment and informing them of drug treatment is a very important part of the prescribing process. There is no simple formula, but patients need to be informed on what they want to know, when they want to know it, and in the way that is most acceptable to them. It is important to use both verbal and written forms of communication and to allow patients to reflect over the information, ask questions, and be further informed over subsequent consultations. Consumer medicine information leaflets can be a useful aid, but require that the clinician understand and be prepared to answer questions raised by them.
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Preparation:
Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Guidelines and Strategies for Safe Computer Charting
Maintain Confidentiality and Security:
Types of Reports III: Telephone and Verbal Reports
Here's an overview of each type:
Telephone Orders
Legal Guidelines for Documentation

