Medicines Management - Secondary Care Prescriptions

SECONDARY CARE PRESCRIPTIONS

Acute Hospital Trusts

Trusts are separate legal entities and will have their own organisational medicines policy for the safe and effective management of medicines in the hospital e.g. in relation to prescribing, storing, transporting, supplying, administering and disposing of medicines. Refer to your relevant local policies, which can usually be accessed via the Trust’s intranet

Medication Documentation

There are usually three main prescribing documents in hospitals:

Inpatient prescription and medication administration record (commonly known as a drug chart)
Outpatient Prescription (note some Trusts use hospital FP10 prescriptions)
Discharge Summary which includes the discharge medication prescription (also known as ‘TTA’ (‘to take away’) or ‘TTO’ (‘to take out’))

As part of the long-term plan for the NHS, Trusts are transitioning from paper to Electronic Prescription Medication Administration (EPMA), which is the implementation of an electronic prescribing and medicines administration system. Some Trusts have already moved to EPMA and an induction is usually provided.

Hospital Inpatient Prescribing

The inpatient prescription and medication administration record or drug chart, is an example of a Patient Specific Direction (PSD) and does not have to follow prescription writing regulations (unlike outpatient prescriptions and discharge medication summaries, which do). A PSD is the traditional written and signed instruction by a prescriber for medicines to be supplied and/or administered to a named patient after assessment of the patient on an individual basis.

Each Trust will have guidance and standards on how to complete the drug chart
Drug charts can vary between Trusts – familiarise yourself with your Trust's drug chart(s) or ask your ward pharmacist to talk you through it
Inpatient drug charts always include patient information and allergy details, in addition they have different sections (the list below is not exhaustive and may vary between Trusts):

Once Only Medications (‘stat’)
Regular Medications
As Required Medications (‘prn’)
Infusion Charts

Some Trusts may have a specific area for medicines or groups of medicines on the drug chart e.g. antimicrobials, antidiabetic medicines, insulin, anticoagulants, oxygen
Other areas of a drug chart may include a medicines management section, where the patient’s medication history prior to admission is documented and there may also be a separate section for VTE (venous thromboembolism) risk assessment
There may also be additional drug charts or prescriptions e.g. diabetic prescription chart, parenteral nutrition prescription, chemotherapy prescription, patient controlled analgesia (PCA) prescription, epidural prescription, syringe driver prescription
- If any are in use for a patient, it should be documented on the main inpatient drug chart and all charts should be held securely together
Some specialist wards or clinical areas may have their own specific drug chart e.g. ITU and paediatric wards
Administration routes are generally indicated as below, however always check your local Trust policy. Routes include:

IM - intramuscular
INH - inhalation
IV - intravenous
NEB – nebuliser
NG - nasogastric
PO - oral
PR - rectal
PV – vaginal
SC – subcutaneous (care should be taken as SC written unclearly can look like SL)
SL – sublingual (care should be taken as SL written unclearly can look like SC)
TOP - topical

Times of administration are usually pre-printed on the drug chart and can be amended by the prescriber if required e.g. when the time interval between amoxicillin doses needs to be spaced out evenly
If new to a Trust, always view some completed inpatient charts before attempting to administer medicines or if unsure ask your ward pharmacist or your supervisor for assistance

Inpatient Medication

Each Trust will have their own local formulary, which lists the medicines approved for prescribing within the Trust
Some Trusts have a formulary specific to their hospital, whilst others may have a joint formulary which covers not only their hospital Trust but also primary care
In some Trusts the content of the BNF is integrated into the local formulary through a web-based application
Non-formulary medication can be obtained, but with the Trust’s permission - ask the pharmacist for further details
Most Trusts encourage patients to bring in their own medication, which assists in determining patient medication history and also reduces the risk of omitting or delaying doses of crucial and/or critical medication
If a patient’s own medicines are deemed suitable, they are usually stored in the patient’s bedside medicine locker to be used for administration during their hospital inpatient stay
Inpatient medication is ordered by the pharmacy team, and usually dispensed and labelled with full directions

This ensures the patient can take the supply with them on discharge, provided it matches their discharge medication summary

The medication history carried out by medical staff at initial assessment has to be confirmed for accuracy and documented within 24 hours of admission by a suitably trained member of the pharmacy team

Any discrepancies identified in the medication history must be resolved and changes documented – this process is known as medicines reconciliation

Pharmacists provide a clinical pharmacy service to most wards
Once the pharmacist has carried out the necessary clinical checks for each medicine, it is customary to endorse and sign the drug charts in green ink

This also distinguishes pharmacy input from the prescribing process

It is normal for pharmacists to discuss prescriptions with the prescriber for clarification and provide medicines management support to doctors and nurses
A medicines information service is usually available as part of the pharmacy department
- This service can be accessed by all healthcare professionals for any medicines related queries

Discharge Medication

The discharge medication prescription must follow prescribing writing regulations
Depending on Trust Policy, patients will usually be provided with at least 7 to 14 days medications on discharge, but this can vary according to the Trust
Details of the discharge medication and the prescription are often part of the discharge summary
To prevent delays in discharge, once a discharge prescription is written, the Pharmacy team must be informed in a timely manner
On discharge, a copy of the summary is provided to the patient and also sent to their GP
The summary must state if a discharge medication is to be stopped, continued or the dose titrated along with any monitoring or review requirements
If any medication during the hospital admission was discontinued, changed or newly started, this must be stated on the discharge summary with the reason why

Outpatient Medication

Outpatient prescriptions vary between Trusts but must follow prescribing writing regulations
In some Trusts, outpatient prescriptions are dispensed by community pharmacies located on the Trust premises rather than the hospital pharmacy department
Usually urgent or hospital-only medications are prescribed on an outpatient prescription
In England, prescription charges apply unless exempt
Some Trusts allow use of a hospital FP10 (FP10HP) which can only be dispensed by a community pharmacy

Transfer of Care

Ensure communication is complete and clear when transferring care
It should be specified who is responsible for monitoring and reviewing the patient