Canterbury DHB

Prescribing Instructions for Medicines

General Advice

1. Prescription writing and delivery:
   • Prescribers may only prescribe for patients in the care of CDHB.
   • Prescribers must use approved CDHB prescription forms, electronic or paper.
   • Where available, electronic prescribing and delivery to the pharmacy is preferred.
   • Faxing is the least preferred option for prescription delivery. If faxing or providing paper prescriptions, ensure printer settings are changed to one-sided printing before printing and/or faxing.
2. Information that must be made known to the patient:
   • Any changes to therapeutic regimen during admission, and why (e.g. medicines stopped, started, and any changes to doses).
   • Any proposed changes (e.g. reducing dose of prednisone).
   • Any monitoring required (e.g. INR, digoxin concentrations).
3. Funding issues:
   • PHARMAC does not fund all medications for use in the community. If unsure, ask the ward pharmacist. Alternatively, information about medicine funding is available in the PHARMAC Pharmaceutical Schedule (Section H for hospital use; and Section B for community use).
   • Some medicines require a request to PHARMAC for "special authority" approval in order to be funded – see www.pharmac.health.nz.
   • Apply for Special Authority.
     • Apply for electronic "special authority" (new application) for immediate authorisation of special authority medicines (sign-up needed).

       The website is sometimes not available. Easiest path is to try again later. If that is not practical, see third bullet about secure email option.
       If there is an issue with the Ministry of Health’s security certificate for this site, you will receive the “This site is not secure” message. Click on “More Information” and “Go on to the web page (not recommended)” and you will be able to proceed.

     • Most special authority items are processed immediately. Contact the ward pharmacist if there is an anticipated problem with community supply of the medicine.
     • If unable to apply electronically, apply by completing the relevant paper form and discuss with the ward pharmacist.
4. The patient or caregiver should be confident about the prescribed medicines aided by:
   • Verbal counselling from doctor, pharmacist, or nurse.
   • Patient Information Leaflets (PILs).
   • Providing or updating the patient's yellow medications card. Discuss with ward pharmacist or nurse.
   • Employing a compliance aid e.g. blister pack when appropriate. Discuss with ward pharmacist.
   • Community medication management service may be available. Discuss with ward pharmacist.
5. Prescriptions should always be clear e.g.:

Inpatient Charting

General advice for inpatient prescribing

• There is a dual method of prescribing – electronic and paper. Where available, electronic is preferred unless not safe (e.g. complex infusions).
• Always check any update allergy status before prescribing. For more information see the Adverse Drug Reaction guideline.
• Use of medicines within hospitals should be from the Hospital Medicines List (HML). See this guidance if using medicines not on the HML: Use of Medicines Outside PHARMAC Hospital Medicines List (HML) Restrictions.

  All New Zealand DHB hospitals are required to use medicines on the PHARMAC Hospital Medicines List (HML). Occasionally there are good reasons to treat a patient with a medicine that is not on the HML or use a medicine outside of HML indication restrictions. Clinicians who wish to prescribe outside the HML for an individual patient whose clinical circumstances are exceptional need to apply for approval using a Named Patient Pharmaceutical Assessment (NPPA) application. The process at CDHB is summarised in the flowchart below.

  Download a printable version of the flowchart.

  

• Prescriptions should use the generic medicine name when there is only one active ingredient. Insulin is an exception which must be prescribed with brand.

Electronic prescribing (MedChart)

Enter and/or update adverse drug reactions (Allergies and Intolerances box) on MedChart.

• Follow MedChart training and help advice found in MedChart in Reference Viewer.

• Some prescriptions are always on paper (e.g. insulin infusions) – refer to prescribing guidance below for paper drug charts.
• Use "Chart Exists" in MedChart to highlight medicines prescribed elsewhere.
• Patients who have been admitted through the Emergency Department (ED), or transferred from Intensive Care (ICU) or from a procedural area may have a paper drug chart (National Medication Chart). Check before prescribing or administering in MedChart.
• Cancer chemotherapy is usually prescribed in MOSAIQ by senior doctors (not MedChart).

Paper drug chart prescribing

• Prescribe on a National Medication Chart.
  • National Medication Charts are used in ED, ICU, and most procedural areas (e.g. interventional radiology).

Enter and/or update adverse drug reactions (Drug Reactions box) on National Medication Charts.

• The patient's name must be clearly indicated.
• On the National Medication Chart, prescriptions must be signed by the prescriber and accompanied by the prescriber's name printed legibly and in CAPITALS.
• Write the medicine name in CAPITALS.
• To change prescriptions, cease and re-chart (e.g. if changing dose).
• Prescriptions should use the generic medicine name when there is only one active ingredient. Insulin is an exception which must be prescribed with brand.
• Do not abbreviate the name of any medicine or chemical because the wrong medicine may be given, e.g. MTX could be methotrexate or mitoxantrone.
• Use of medicines within hospitals should be from the Hospital Medicines List (HML). See this guidance if using medicines not on the HML.

  All New Zealand DHB hospitals are required to use medicines on the PHARMAC Hospital Medicines List (HML). Occasionally there are good reasons to treat a patient with a medicine that is not on the HML or use a medicine outside of HML indication restrictions. Clinicians who wish to prescribe outside the HML for an individual patient whose clinical circumstances are exceptional need to apply for approval using a Named Patient Pharmaceutical Assessment (NPPA) application. The process at CDHB is summarised in the flowchart below.

  Download a printable version of the flowchart.

  

All Outpatient and Discharge Prescriptions

Discharge prescribing is part of the writing of the discharge summary, in Health Connect South.

See Writing Discharge Summaries – Hints and Tips on Hospital HealthPathways.

1. Prescription writing and delivery:
   • Where possible, write and send prescriptions to the patient's pharmacy electronically. For instructions on how to do this, see generating electronic prescriptions on the CDHB intranet.
   • Exceptions to electronic prescription writing and delivery are:
     • Controlled drugs

       Controlled drugs

       • Class A and class B medicines (such as morphine) require a controlled drug prescription, which must:
         • be written on a triplicate-controlled drug prescription form H572 (see example prescription – these are found in controlled drug cupboards).
         • be entirely handwritten by the prescriber including patient name, NHI, and full physical address. Note that a PO Box is not acceptable. Do not use patient labels.
         • be written in CAPITALS.
         • if patient younger than 12 years old, include date of birth.
         • include medicine strength and formulation in words and figures. This includes specifying oral liquid strengths (e.g. 5 mg/mL). Underline and initial unusual doses for clarity.
         • include total quantity (rather than duration) in words and figures. Note that the maximum quantity is one month. Prescribe 10-day supply with 2 repeats; or 7-day with 3 repeats. Underline and initial unusual quantities for clarity. Note: PRN alone is not acceptable.
         • have maximum of two items per prescription. Cross out blank section if one item only required.
         • be signed by the prescriber and accompanied by the prescriber's name printed legibly and NZMC number; and dated.
         • include hospital address under Practitioner's Name (for example, "Christchurch Hospital" is not adequate. Write "Christchurch Hospital, 2 Riccarton Ave, Christchurch" or equivalent, depending on campus).
         • be given to the patient or caregiver to deliver to a community pharmacy. Give all three copies.
         • inform patient or caregiver that the prescription must be presented to a pharmacy within 7 days.
         • contact the pharmacy to ensure supply available for infrequently used medicine products or strengths.
       • Class C medicines (such as codeine and diazepam) should be written electronically and delivered to the patient's pharmacy via ERMS. Additionally:
         • annotate in the Prescriber Notes to Pharmacy Field in Health Connect South that the prescription is a Class C controlled drug and that a signed copy is being posted.
         • print and sign a paper copy of the prescription.
         • post the signed paper prescription to the patient's nominated pharmacy. Do not give a paper copy to the patient or caregiver, if sent through ERMS.
     • Pharmacies outside of CDHB.
       • Pharmacies that cannot receive prescriptions electronically via ERMS (e.g. outside of CDHB) should have prescriptions delivered by email.
         • When emailing prescriptions, use your CDHB email address and ensure that you are easily identifiable and contactable (provide a contact telephone or pager number).
         • Faxing prescriptions and providing paper prescriptions to patients are the least preferred options – however, it may be required for patients filing prescriptions in other DHBs.
         • If faxing or providing paper prescriptions, ensure printing settings are changed to one-sided printing before printing and/or faxing.
     • Hospital supply of medications to use in the community.
       • On discharge, most patients who need supply of medications will have a prescription as described above. Exceptions are:
         • In some specific situations, medications will be dispensed by the hospital pharmacy. Discuss with your ward pharmacist or dispensary (ext 88399).
         • Out of hours, a doctor may dispense a quantity from ward stock according to the Take Home Medications policy. Nurses cannot dispense medications for leave or discharge. For more details, see the Out of hours guidance and Take Home Medications Policy.
         • In some areas, a doctor may prescribe and supply a medicine (such as single doses for before surgery in pre admission clinics). For more details, see the Take Home Medications Policy.
2. Duration or quantity:
   • PRN medications must be prescribed with a quantity rather than duration, e.g. codeine PO 30 mg TDS prn – 30 tablet supply. If this was prescribed as 30 days, the pharmacist would dispense 90 tablets which may be excessive and may promote abuse.
   • For long-term medicines that are new or need review by the GP, consider short durations, e.g. 2 weeks.
3. Funding issues:
   • PHARMAC does not fund all medications for use in the community. If unsure, ask the ward pharmacist. Alternatively, information about medicine funding is available in the PHARMAC Pharmaceutical Schedule (Section H for hospital use; and Section B for community use).
   • Some medicines require a request to PHARMAC for "special authority" approval in order to be funded – see www.pharmac.health.nz.
   • Apply for Special Authority.
     • Apply for electronic "special authority" (new application) for immediate authorisation of special authority medicines (sign-up needed).

       The website is sometimes not available. Easiest path is to try again later. If that is not practical, see third bullet about secure email option.
       If there is an issue with the Ministry of Health’s security certificate for this site, you will receive the “This site is not secure” message. Click on “More Information” and “Go on to the web page (not recommended)” and you will be able to proceed.

     • Most special authority items are processed immediately. Contact the ward pharmacist if there is an anticipated problem with community supply of the medicine.
     • If unable to apply electronically, apply by completing the relevant paper form and discuss with the ward pharmacist.
4. Rest homes:
   • Liaise with the patient’s rest home to confirm their regular community pharmacy.
   • Rest homes often require a full prescription of all their regular medications.
   • Ceased or changed medicines must be clearly documented.
   • Medicines with variable dosing schedules must be clearly prescribed, for example, warfarin dosing until the next blood test.
5. Blister packs:
   • If a patient is usually prescribed blister packs and had changes to their medicines, this must be organised with their regular community pharmacy if open.
   • It is recommended to prescribe all regular medications to be included in a blister pack.
   • Blister packs take time to prepare and early liaison is necessary.
   • If the patient has medications at home that have been stopped or changed, encourage them to return these to their pharmacy.
6. Less commonly prescribed medicines and compounded liquids:
   • Some less commonly prescribed medicines and compounded liquids may not be readily available at all community pharmacies. Pharmacies may also not be able to order from suppliers after hours.
   • Early liaison with the community pharmacy is important to address any potential issues.
7. Funding:
   • Ensure discharge medications are funded in the community by checking the PHARMAC Schedule (Section B) and special authorities (where required) are completed electronically.
   • Medications that are only funded in hospital on the HML must be supplied by the hospital pharmacy only (e.g. cefuroxime for indications other than endocarditis).
   • Contact the ward pharmacist for advice.
8. Special circumstances:
   • Palliative care: for discharge on subcutaneous syringe drivers, refer to the Palliative Care guidelines.
   • Opioid substitution: must not be prescribed on discharge, refer to the opioid substitution guidelines.
   • Home Intravenous Antimicrobials: to arrange referral, contact the infectious diseases registrar or consultant via the switchboard.
     • If the patient is thought to be suitable for home intravenous antimicrobial therapy, the infectious diseases registrar or consultant will discuss the patient with the home intravenous nurses.
     • If required (e.g. to confirm that the referral has been sent to the nurses), call the nurses on 027 290 0823 or pager 8839.
     • Inform the patient, and clearly state in the discharge summary that the referral has been made.

After-Hours Discharge and Community Prescribing

In addition to the general advice above, contact the patient's community pharmacy:

• Confirm if the patient’s regular community pharmacy is open.
  • Opening hours and contact details for after-hours pharmacies are available on Healthpoint.
  • Contact the pharmacy to confirm they will be available following patient discharge.

Funding:

• Ensure discharge medications are funded in the community by checking the PHARMAC Schedule and special authorities (where required) are completed electronically.
• Medications that are only funded in hospital on the HML must be supplied by the hospital pharmacy only (e.g. cefuroxime for indications other than endocarditis).
• Contact the on-call pharmacist for advice out of hours.

Supply of hospital medicines to take home after hours:

• On discharge, most patients who need supply of medications will be given a prescription to fill at their community pharmacy when it opens. Out of hours, a doctor may dispense a quantity from ward stock in some specific situations.
  • Some medications are only dispensed by the hospital pharmacy. Contact the on-call pharmacist for advice out of hours.
  • A doctor may dispense a quantity from ward stock to provide necessary medication until the community pharmacy opens, according to the Take Home Medications policy. Nurses cannot dispense medications for leave or discharge. For more details, see the Take Home Medications Policy.
  • In some areas, a doctor may prescribe and supply a medicine (such as single doses for before surgery in pre-admission clinics). For more details, see the Take Home Medications Policy.

Special circumstances:

• Home Intravenous Antimicrobials: to arrange, contact the on-call infectious diseases registrar or consultant via the switchboard.
  • If the patient is thought to be suitable for home intravenous antimicrobial therapy, the infectious diseases registrar or consultant will discuss the patient with the home intravenous nurses.
  • If required (e.g. to confirm that the referral has been sent to the nurses), call the nurses on 027 290 0823 or pager 8839.
  • Inform the patient, and clearly state in the discharge summary that the referral has been made.

must be prescribed or recommended by a consultant.

Topic Code: 132290