REPEAT PRESCRIBING GUIDANCE INTRODUCTION
The purpose of this document is to set out the methods by which a repeat prescription will be issued and the roles and responsibilities within the practice. THERE ARE FOUR STAGES:
1. Initiation/ Request 2. Production/ Authorisation 3. Clinical control/ Review 4. Management control
The GP should retain an active involvement throughout the repeat prescribing process and should not delegate any entire part of the process to ancillary staff. Those stages in bold above are entirely the responsibility of the GP. 1. Initiation/ Request
The decision to transfer a drug from an acute prescription to a repeat prescription must
always be made by the doctor after careful consideration of whether the drug has been effective, well-tolerated and is required long-term. (The patient should be seen, or at least spoken to, at this stage to ascertain the above and to check compliance). It is the duty of the doctor at this stage to ensure that the patient understands the repeat prescribing process and what is required of them.
Care should be taken to ensure the repeat record is accurate, quantities for each drug
are synchronised where possible and review dates are entered, at least once every 6 months or more often if required. See Appendix A for a synchronisation form which may be handed to the patient to complete.
Drugs should be linked to medical conditions within the clinical system as appropriate.
This will largely be the responsibility of the patient. The patient should be given a list of drugs they are currently taking on repeat
prescription, preferably as a computer-generated list (usual y forming the right hand side of the prescription slip).
The patient, or his/her representative, must have an active role in requesting a repeat
The patient should be encouraged to indicate on the repeat request slip which drugs
they require when a request is made. If they have left the form blank and it is not obvious from their computer record which medication is needed, then the patient should be contacted if possible, rather than al the medication given.
Only urgent telephone requests or telephone requests from housebound patients can
be taken. Patients should allow 2 working days (48 hours) for requests to be dealt with. This allows adequate time for a good quality repeat prescribing system to operate. For postal requests, to be returned via an SAE, patients should allow one week.
Patients should be encouraged to tel their GP’s if they are no longer taking a repeat
medication. The appropriateness of this can then be assessed and the computer updated to reflect the change. 2. Production/ Authorisation Production
This will usually be the responsibility of the receptionist. Repeat prescriptions should be computer generated from the Repeat Template (never
from Acute Template), as handwritten forms are prone to error and are not considered good practice; only under some circumstances, e.g. specials that are not included on the Computer System Database, are allowed.
A compliance check is preferable at this stage and the computer should normally alert
the user if medication appears to be over or under used. Particular attention should be paid to ‘as required’ drugs and if problems are suspected the doctor should be alerted, preferably before the prescription is produced.
Practices should not supply further repeat prescriptions at shorter time intervals than
have been authorised without agreeing the reason for the early request, e.g. holiday.
Provided there appears to be no problem, a prescription can be generated and left for
the doctor to authorise and sign, with the notes to hand if required, to cross check the validity and appropriateness of the request. Situations where notes or the computer record should always be checked by the doctor include:
1. Where the request slip indicates that a review is necessary or when any of the items requested need to be re-authorised.
2. Where any drug requested by the patient is not on their repeat record
3. Where any of the following drugs are requested:
Benzodiazepines, e.g. Temazepam, Diazepam, Zopiclone,
Zolpiderm (these must only be issued as Acute)
All controlled drugs (please see next section)
4. Where the item requested has been issued less than one month previously.
5. Any request about which the practice staff are concerned or uncertain.
Where additions or corrections are made, the doctor signing the prescription should
initial or countersign against them. A record should be made of any handwritten alterations to subsequent computer-generated prescriptions.
Blank prescriptions should never be signed by a doctor for later completion by
him/herself or a delegate. To do so is in breach of terms of service.
Unused space should be cancel ed out under the last drug by a computerised
mechanism or by the doctor deleting the space manual y.
All repeat prescriptions issued should be recorded on the computer. Practices should store prescriptions awaiting collection in a secure way and have a
standard time limit for collection of repeat medication (e.g. 4 weeks) after which those not collected should be investigated, e.g. no longer required or medication underused etc. In this case, the record of issue should be deleted from the computer and a note made on the computer that the prescription has been destroyed with the appropriate read code. The prescription should be shredded. 2.a. Controlled Drugs
This guidance applies when the fol owing opioid medications are prescribed:
Buprenorphine Diarmorphine Dipipanone Fentanyl Hydromorphone Meptazinol Methadone Morphine Oxycodone Papaveretum
When these medications appear on any prescriptions they must be reviewed and authorised by a duty doctor.
When opioid medicines are prescribed, the healthcare practitioner concerned, or their clinical supervisor, should:•
Confirm any recent opioid dose, formulation, frequency of administration and any other
analgesic medicines prescribed for the patient. This may be done for example through discussion with the patient or their representative (although not in the case of treatment for addiction), the prescriber or through medication records. •
Ensure where a dose increase is intended, that the calculated dose is safe for the
patient (e.g. for oral morphine or oxycodone in adult patients, not normally more than 50% higher than the previous dose). •
Ensure they are familiar with the following characteristics of that medicine and
formulation: usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, common side effects. 3. Clinical Control/ Review
This is solely the responsibility of the doctor, although the nurse can review certain
patients on behalf of the doctor, e.g.: contraception, asthma… The review date is set on the computer for every 6 months. For those patients who need annual review, e.g. chronic stable conditions, reviewing them in their birthday month may serve to remind patients of their obligation to attend for review.
A 28 or 56-day (when condition is stable) supply will be given. A few patients can be
given six months supply, e.g. Oral contraceptives, HRT.
When patients are on several regular long-term medications, quantities should be
prescribed to synchronise repeat intervals. In the UK patient packs are moving towards multiples of 28 days (rather than 30)
When patients are discharged from hospital, their regular medication may have
changed. This is a particularly vulnerable time for errors to occur and ideally the doctor should either amend the repeat record personally or at least check it at the time it is amended as therapeutic decision-making will be required and re-authorisation is essential. The doctor then should sign the discharge letter before is scanned to confirm the right amendments are implemented. Please, pay particular attention to medicines that are only required for short period of time, as they should not be added on the Repeat Template.
The following considerations should be kept in mind by the doctor when carrying out medication review consultations;
1. Control of the condition - is this optimal?
2. Unnecessary medication - can anything be stopped?
Is the patient taking the medication properly? Could the regimen be simplified?Is there a problem with unwanted adverse effects? Check understanding of medication?
4. Monitoring - e.g. phenytoin levels, INR, TFTs, LFTs, U&Es
Methotrexate – check ICE – blood tests (full blood count, U&Es and
LFTs) should have been done within the last three months. Make sure prescriptions are only for 28days, the strength of the tablets prescribed are 2.5mg, with full directions on the prescription and the patient takes it ONLY ONCE A WEEK.
Warfarin – check ICE – INR should have been checked within the last 12 weeks. If there are no results on ICE please contact the Anti-coagulation clinic or the patient.
Lithium – check ICE – Lithium levels should be measured every 3 months; U&Es and TFTs should be monitored every 6 months.
5. Cost considerations - change to generics if appropriate, or consider
change to a more cost-effective treatment (consider PCT formulary and ScriptSwitch)
4. Management control
This would largely be the responsibility of the practice manager.
Practice staff that write, or are involved in the preparation of, repeat prescriptions should be appropriately trained in the practice protocols for repeat prescribing, what their responsibilities are, and the need for accuracy. This should be on going, but is particularly important for new staff.
Liaison with local community pharmacists is essential if procedures are changed that may ultimately impact on them.
An adequate system for the secure storage and use of FP10s should be in place.
The practice computer system holding the prescribing records must be backed-up regularly.
Periodic audit of repeat prescribing will be carried out annually. Setting up a repeat prescription.
The medication to be included on a repeat prescription should be agreed between GP
The importance of the need for regular review of repeat medication should be stressed
It is the responsibility of the patient’s GP to ensure that an accurate up-to-date record
of a patient’s repeat medication is held in their computer records.
Repeat medication prescriptions should last for an agreed length of time, usual y 6-12
months, before medication should be reviewed (although this period can be extended if felt appropriate at the discretion of the prescribing GP).
Provide patients with details of the system operation at an appropriate time (on
registration with the practice, or on commencing a repeat prescription). Posters detailing the operation of the system should be displayed around the practice. Operation of the system
Practice staff are responsible for the day to day running of the system. This should include:
An appointed member of staff being given responsibility for the daily col ection and
processing of all repeat prescription requests.
Routine reauthorisation of repeat prescriptions is the responsibility of the Doctor. If
items requested have expired and need reauthorisation the patient is required to attend a medication review, unless housebound. If housebound, the GP is then responsible for deciding whether to automatical y re-authorise the repeat prescription or to provide a home visit. When to refer the prescription back to the doctor
If anything is unclear with a repeat prescription request refer back to the prescribing
If a patient requests an item which is not included or differs from the details recorded in
their records, they should be referred to the GP.
If a patient under or over orders items on their repeat prescription indicating poor
compliance, this should be highlighted with the GP. Monitoring of repeat prescribing
Ideal y a GP should carry out a medication review when:
A block of repeat medication comes to an end. Patients attend for monitoring of the condition requiring repeat treatment. Opportunistical y should a patient attend with another complaint.
The review should consist of an assessment of the patient’s condition and compliance with prescribed medication. If any repeat medications are no longer being requested, an attempt should be made to ascertain the reason why and appropriate action taken. QUALITY ASSURANCE
This procedure should be reviewed annually.
This Repeat Prescribing process has been shared with al relevant health professionals and practice staff.
Any changes to the process will be notified as necessary and the PROTOCOL / POLICY / PROCEDURE REVIEW SHEET (at the end of Policy) will be updated. Repeat Prescribing Flowchart
Following agreement between patient and doctor to commence medication on a repeat prescription:
Set up appropriate details in patients medication records. Give patient details of
Request collected by appropriate member of staff for processing
Does prescription request require clarification or reauthorisation before it can be processed any further?
Arrange medication review with GP or refer
Is it appropriate to make any brand name to generic name switches?
Appendix A – Patient Synchronisation Form Dear patient: Synchronising your repeat medicines
We notice that on your last request for medication you only asked for some of your regular items. We would like to arrange that the renewal of all your medicines happens at the same time - this will have advantages for you, as you will be able to pick up all your medicines together, reducing the number of times you have to order / collect your medication.
To achieve this we will issue a single synchronising prescription. To help us with this synchronisation please complete the form below and hand it in the next time you order your repeat prescription. When you next collect your medicines you will receive different quantities of each to bring them in line. In the future you should be able to order al your regular items together – there will be a couple of exceptions, where the dose of medication varies i.e., painkil ers, anticoagulants, insulin.
If you have any questions or queries then please speak to one of the reception staff. Please complete the first three columns of the table, following the first example: PRACTICE USE ONLY medication tablets 1 MONTH Supply for medication do you SUPPLY = synchronisation prescription EXAMPLE Aspirin One daily
PROTOCOL / POLICY / PROCEDURE REVIEW SHEET
Vincent Cavaillès Signalisation hormonale environnement et cancer Linares A, Dalenc F, Balaguer P, Boulle N, Cavailles V. 2011. Manipulating protein acetylation in breast cancer: a promising approach in combination with hormonal therapies? J Biomed Biotechnol 2011: 856985 Chambon M, Orsetti B, Berthe ML, Bascoul-Mollevi C, Rodriguez C, Duong V, Gleizes M, Thenot S, Bibeau F, Theillet
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