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dentist prescribing benzaclin

Discussion in 'Pharmacy' started by rxbaby, Mar 24, 2015.

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  1. JoBreeze

    JoBreeze 2+ Year Member

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  3. Dred Pirate

    Dred Pirate 2+ Year Member

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    1. I understand how MD's work - some of my best friends are - I was just illustrating an example of how it is not a black or white issue re: scope of practice. I would have no issue filling it, but I can see why if the Rph didn't know the background, they may think it is a grey area.. My issue with the sports med doc writing adhd meds is that is could be construed as a performance enhancing drug. There are many examples of athletes being disqualified because of testing positive for adderall
     
  4. DruggieDoRight

    DruggieDoRight 2+ Year Member

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    I think we're missing the obvious solution.

    If you have a question about a prescription or something feels fishy, call the prescriber! Hopefully, they can come up with something besides, "I'm the doctor, do as I say." Otherwise you don't have to fill it. Someone who is a dermatologist may practice in other areas or work at different clinics. Being a dermatologist doesn't preclude one from being a GP on the side (you know, other than not being paid as much as a derm).
     
  5. npage148

    npage148 Senior Member 10+ Year Member

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    Why do you think you need to police PEDs on a pharmacy level? If you want to do something about it call in an anonymous tip to the USADA. Also, what if the athlete has a TUE filled to take adderall. Then there is no issue for them taking it in or out of competition. But not filling adderall simply becaue it's written by an ortho is stupid Would you be worried about an ortho writing for beta blockers? Those are banned in shooting comps. Or diuretics? Those are banned as well.
     
  6. JoBreeze

    JoBreeze 2+ Year Member

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    Exactly.

    And as I explained earlier most sports docs are internists, family physicians and pediatricians, not orthos.
     
  7. zelman

    zelman 7+ Year Member

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    The DEA’s regulations (21 C.F.R. § 1306.04) addressing corresponding responsibility state

    A prescription for a controlled substance to be effective must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice. The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription. An order purporting to be a prescription issued not in the usual course of professional treatment or in legitimate and authorized research is not a prescription within the meaning and intent of section 309 of the Act (21 U.S.C. 829) and the person knowingly filling such a purported prescription, as well as the person issuing it, shall be subject to the penalties provided for violations of the provisions of law relating to controlled substances.

    Now, tell me how treating ADHD is in the usual course of the professional practice at a sports medicine office.

    I'm not saying that individual is unqualified to prescribe the meds. Just that it is illegal for them to do so based on their position of employment.
     
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  8. Old Timer

    Old Timer SDN Advisor SDN Advisor 10+ Year Member

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    No, you are 100% wrong. Just because you specialize in Sports Medicine, you can still treat ADHD just like any other MD. As long as the prescriber is treating the patient and keeps medical records it is allowed. You are just wrong. If you suspect something, you call and document. A blanket refusal is unprofessional.
     
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  9. zelman

    zelman 7+ Year Member

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    So what does "usual course of their professional practice" mean?
     
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  10. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    Being a physician is their usual course of professional practice, with appropriate record keeping and an appropriate physician-patient relationship.

    Basically, a physician hanging off the edge of an ice cream truck giving out Rx's in exchange for hookers and blow = not the usual course of professional practice.
     
  11. npage148

    npage148 Senior Member 10+ Year Member

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    That law is also not profession specific. So usual course of practice related to the profession, ie dentist, md, dpm etc.
     
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  12. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    So I stand corrected, that means any physician, dentist, NP, PA, etc... hanging off the ice cream truck is not usual course of practice.
     
  13. BenJammin

    BenJammin No Apologies 5+ Year Member

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    What about an urgent care doctor prescribing Adderall XR? Is that appropriate?
     
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  14. Old Timer

    Old Timer SDN Advisor SDN Advisor 10+ Year Member

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    You have doctor patient relationship with this patient.
    You keep appropriate medical records.
    The treatment is appropriate based on the facts in the medical record.
     
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  15. zelman

    zelman 7+ Year Member

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    How could your interpretation that there is a federal requirement of a "doctor-patient relationship" be fulfilled in states where self-prescription of controlled substances is permitted?

    If a record is required, how can any controlled substance be dispensed appropriately without receiving such a record (something I have never seen done in retail)?

    How can an individual without proper training necessary to warrant prescriptive authority determine the appropriateness of treatments based on a medical record (that they have never seen)?
     
  16. Old Timer

    Old Timer SDN Advisor SDN Advisor 10+ Year Member

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    That's what a medical practice is. As for self prescribing, it's allowed in some states, but that does not release the prescriber from keeping good medical records.

    The prescriber has to keep medical records. You don't get to see them. But you can call and get the necessary documentation if you have any questions.

    Easy, you are a pharmacist, right? I got a script from a GP for Amoxicillin for pre-medication. I asked for the diagnosis and when I was told it was Mitral Valve prolapse I knew it was inappropriate. I informed the office and faxed the guidelines to the MD. They decided not to do it. See, I didn't need to see the chart. I had an issue and I asked a question. Similarly, if I get an Rx for Phenergan w/Cod from a OB/GYN or a pediatrician, I pick up the phone see what's going on. It's like pornography, I know it when I see it.

    I'm wary of young, strapping healthy looking young men getting 180 Oxy 30's. I have pretty much stopped filling any Oxy 15's or 30's unless it's from an oncologist. I spoke to the the pain management guy at the local hospital and he said if you have more than 2 people a month getting Oxy 30 from a practice, you should be suspicious. You know it when you see it......
     
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  17. zelman

    zelman 7+ Year Member

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    So you know things when you see them and I'll know things when I see them and everyone is always correct. We're all winners.
     
  18. Ackj

    Ackj 7+ Year Member

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    So we've beaten the dead horse that specialists were at least at some point trained as a plain old MD. Do they still maintain that knowledge/expertise? I don't know what sort of CE requirements they have, but somebody who spends 100% of their time as a dermatologist probably has very little reason to be aware of the updated lipid guidelines. I see a situation here akin to the dangerous 95 year old drivers: once you've got the license, it's yours forever. I'm sure most docs are going to be responsible and not prescribe something they aren't comfortable with, but if there weren't people toeing the line, we wouldn't be having this discussion.
     
  19. W19

    W19 SDN Gold Donor Gold Donor Classifieds Approved 2+ Year Member

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    ...
     
    Last edited: Mar 26, 2015
  20. Old Timer

    Old Timer SDN Advisor SDN Advisor 10+ Year Member

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    No, I take each script as it comes and you make blanket declarations without any real evidence of impropriety.
     
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  21. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    It is fair to refuse to fill any prescription that one has reason to believe is not within the usual course of practice (scope of practice, doctor-patient relationship, inappropriate use) For example, if a IM doctor writes a RX for methadone to treat a heroin addiction, this would be outside his practice scope, if he writes it for pain, its legal. If a dentist writes a prescription for Vicodin for someone with a sprained ankle, this is outside practice scope, but s/he can write for Vicodin for tooth pain. If an ophthalmologist writes a prescription for Clomid, even though this is within his scope of practice, it would be fair to question if he has the appropriate doctor-patient relationship with the patient. MD/DOs/APN's can not prescribe for pets, and vets cannot prescribe for humans. Some cases are clear-cut, many cases are gray, and I usually give the benefit of the doubt to the prescriber (if the prescription is otherwise appropriately written.)
     
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  22. JoBreeze

    JoBreeze 2+ Year Member

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    It absolutely is not illegal and that is not what we are discussing. The legality and your "comfort" dispensing are two very different things, stop conflating them.

    Plenty of sports docs actively continue practicing family medicine. For college athletes, sports medicine physicians are often their primary care providers, which is extremely appropriate.
     
    Last edited: Mar 27, 2015
  23. JoBreeze

    JoBreeze 2+ Year Member

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    Of course it's a legit discussion, but there is undoubtedly still confusion as to who is qualified to treat what. You don't know that the radiologist/dermatologist doesn't regularly volunteer at a free clinic practicing general medicine. I personally know several that do.
     
  24. drcrispmd

    drcrispmd 2+ Year Member

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    What about the family doc who writes amoxicillin for tooth abscess? This is done all the time at my clinic because it is pretty obvious if there is an abscess and patients either cannot afford a dentist or can't get into one for several days/weeks.

    Also do you ask patients to why their doc is prescribing certain meds all the time. Vicodin for sprained ankle not appropriate, but that is another discussion. What if that person had sprained his ankle a few days before a dental procedure?
    Also OBGYN treat colds in pregnant women. So phenergan with codeine syrup would be appropriate for them. They also mange thyroid among other primary care issues too and this is in their scope.

    Some specialist are board certified in IM and their speciality and some of them practice both. In the same office.

    It isn't good practice to prescribe anything controlled outside the office period. With the state laws being so strict, I would not do it. Radiologist have had 1 year of general medicine residency which makes them eligible for license to be a general practioner.

    Some docs do multiple residencies.

    Some family med sport med doc do both primary care and sports med out of the same office.
     
    Last edited: Mar 27, 2015
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  25. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    I agree with above. I really think people are confusing professional judgement with scope of practice. They are not mutually exclusive and the former encompasses the latter.
     
  26. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    It can be. Many primary care clinics contract urgent care services with access to patient charts, or staff after-hours themselves with an outside team. So an urgent care MD is much like a fill-in doc at the clinic when your regular MD is on vacation.

    Standard judgement applies, though. If your patient is not a regular and pays cash and comes in at 11pm with a new Rx for Adderall XR and urgent care is closed/MD unable to be reached, use professional judgement not related to "scope of practice."

    I mean, what do we tell patients who are begging and need controlled meds and their GP failed to provide refills during the day? Go to the ER/urgent care.
     
  27. PharmNerdMatt

    PharmNerdMatt 2+ Year Member

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    I think there are two different discussions. (Maybe three going on here).

    One is "scope of practice" relating to prescribing. A license to practice medicine legally allows you to write a prescription for any drug/any condition (excluding needing an X DEA #) A license to practice dentistry/optometry/etc does not.

    Then there is "usual course of practice." This means that it is not in the usual course of practice for a cardiologist to prescribe seizure medications. However, it is certainly within his rights as someone with a license to practice medicine to do so. If you are going to refuse these prescriptions, it should be based on the fact that the Rx is wrong/inappropriate, not because the prescriber isn't a neurologist.
     
  28. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    Yup. People are confusing all of these.
     
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  29. npage148

    npage148 Senior Member 10+ Year Member

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    Nope, usually scope of practice in terms of that DEA law quoted is only intended to define roles between dentists, doctors, podiatrists etc. It does not have anything to do with a specialiaty being restricted. The idea that it is illegal for a cardiologist to prescribe Phenytoin is simply stupid. They are a doctor they can prescribe whatever they want legally.
     
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  30. zelman

    zelman 7+ Year Member

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    Keep in mind that the terms in question have never been defined in law. They mean whatever any DEA agent or judge wants them to mean.
     
  31. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    The family doctor is treated the infection, this is within their scope of practice (now if the family doctor pulled out some pliers and wanted to physical remove the tooth, then they are overstepping their scope of practice.)

    Normally, I do not ask a patient why they are taking an RX (unless I am concerned about the dose, some medications are given at a high dose, but only for certain indications), But if the patient is actually stupid enough to come in and brag about their dentist friend giving them an RX for Vicodin (yes, I actually saw this happen), then yes the pharmacist should refuse to fill that RX, because the dentist is writing outside his scope of practice. So warning to dentists, if you are going to practice outside of your scope of practice, you should make sure your patient friends know to keep their mouths shut.

    Edited to add, neither I, nor the patient, not the dentist, could really know if the patient had a sprained ankle, since none us have been trained to diagnose sprained ankles. This is apparently what the patient thought he had, and the dentist was willing to treat it.

    Everything else you said, I agree with, MD/DO's can prescribe any FDA approved drug, for a legitimate health concern within their scope of practice.
     
  32. drcrispmd

    drcrispmd 2+ Year Member

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    I have been tempted to do this before because I have repeat customers really wanting pain meds instead of antibiotics and will not go get the tooth pulled. My policy is antibiotics only for tooth abscess. But when I see you 3 times in a month for tooth abscess and know you asking for lortab because "antibiotics don't work on you" I am tempted to get the pliers out (never have and never will).
     
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  33. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    I can understand that temptation. For doctors that are going to prescribe them both, I highly recommend putting both RX's on the same script (if allowed in your state), and writing on the RX that the pain medication RX can only be filled if the antibiotic RX is filled. Pharmacists generally, will require patients to fill both, and when the patient says they can only afford one, I tell them the antibiotic is more important, so they need to get that one. With the new e-rx's, many times doctors will just print them on separate sheets for the patient, and then the patient conveniently only brings in the pain medication one (so the pharmacy has no idea that they also have an antibiotic one.)
     
  34. drcrispmd

    drcrispmd 2+ Year Member

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    I do not prescribe pain medicine period for tooth abscess because the antibiotic will help the pain by clearing the infection.

    I do that for kidney stone pain and Flomax. Have to get it in order to get pain med and hand write the rx out instead of faxing it.
     
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  35. SClENCE

    SClENCE 2+ Year Member

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    A dermatologist may very well fulfill all three of YOUR requirements that define "normal scope of practice" but it still doesn't make a prescription for Adderall fall within their normal scope of practice. Keeping record of a prescription and having a relationship with the patient in no way makes a prescription for Adderall any less unusual in this situation, weather it is appropriate or not. This is not to say the the MD isn't qualified to treat the condition... but the law says it has to be in the normal scope of practice and your 3 points no not at all define "normal scope of practice". Meanwhile, a family doctor could write a prescription for Lisinopril that fails to meet all 3 of your requirements and the prescription would STILL fall in his normal scope of practice... because it is expected that a family doctor would treat high blood pressure.

    Now if by normal scope of practice they are referring to dentist vs doctor vs podiatrist then this argument is invalid... but I'm not convinced that this is the case.
     
    Last edited: Mar 28, 2015
  36. owlegrad

    owlegrad Uncontrollable Sarcasm Machine Staff Member SDN Administrator 7+ Year Member

    I thought drugs in different schedules had to be written on separate blanks based on federal law?
     
  37. zelman

    zelman 7+ Year Member

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    Nope
     
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  38. Ackj

    Ackj 7+ Year Member

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    That's a really good rule of thumb. If your patient's mouth is shut, you're probably not practicing dentistry.
     
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  39. Lnsean

    Lnsean 7+ Year Member

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    Jesus Christ...I can't believe we're having a heated discussion over this. Use your professional judgement. This is the reason why this profession is going down the toilet; they let anyone graduate with a pharmD now that can't make a simple clinical decision.
     
    Last edited: Mar 28, 2015
  40. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    well that's a boring thread
     
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  41. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    I'm pretty sure its a state law in certain states.
     
  42. Old Timer

    Old Timer SDN Advisor SDN Advisor 10+ Year Member

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    Well look up any state law and you will not seen mention of any specialization. A doctor is a doctor and if they have a valid license, they can write whatever they want. Scope of practice applies to their license as governed by the law of the state. When they start giving out cardiologist licenses you would be correct.
     
  43. SClENCE

    SClENCE 2+ Year Member

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    Yeah I think I agree with you on this. No specialty is limited on what they can prescribe. That being said, I still personally wouldn't blindly fill for example Adderall from a dermatology clinic.
     
  44. Old Timer

    Old Timer SDN Advisor SDN Advisor 10+ Year Member

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    Not the question. You call and verify. But you CANNOT tell the doctor it is out of his/her scope of practice.....
     
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  45. Lnsean

    Lnsean 7+ Year Member

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    We're not saying that they cannot write for them; we're saying that we cannot fill it. I'd let them know that they're prescribing outside of their standard of care and I would not fill it. Simple as that.

    And no, there's no circumstance where you should fill an Adderall prescription written by a dermatologist. You are setting yourself up for liability. "Documenting" stuff does not release you of the responsibility of due diligence:

    "hey doc, did you write for all #360 pills of oxycodone?"
    "yes, yes I did. He has chronic pain syndrome (insert dx code)"
    "really, you don't say..."
     
    Last edited: Mar 30, 2015
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  46. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    I think you're trying to address 3 different things here:

    1) "Standard of care" is completely different from scope of practice and appropriate prescriber-patient relationship. Amphetamines are standard of care for ADHD, whether you're a dermatologist or a GP.

    2) what if that dermatologist subs in for his friend's primary care practice or in a hospital as a hospitalist discharging a patient to continue ADHD therapy? He magically gains the ability to prescribe Adderall then? Gimme a break, there's no logic to that and we've beat that over like a dead horse.

    Dermatologist in a dermatology clinic for a dermatology patient being seen for a dermatology issue...then you can say no-go on the script. Dermatologist alone does not tell the whole story.

    3) wtf does oxy #360 have anything to do with anything? I have oncology patients with chronic pain that meet or exceed this quantity.

    So three completely different thoughts in your post, which is sortof emblematic of this clusterfracas of a thread.



    Side note/thoughts in my head: thank god I don't have to deal with this **** in the hospital...trauma writes for beta blockers and clicking "continue all home meds" in the chart? Sure, have it all, as long as the dose is right! No questioning scope of practice there.
     
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  47. SClENCE

    SClENCE 2+ Year Member

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    I can tell a doctor that I'm not filling it... but this wouldn't be the case as in this situation I wouldn't even call the doctor; I would tell the patient that I'm not comfortable filling it. Nothing the doctor could say would change the way I feel about it thus a call is not necessary. Calling the doctor is a waste of my time as it would accomplish nothing.

    And what makes you think I would tell a doctor that they are prescribing out of their scope of practice? Don't put words in my mouth... I never even mentioned calling a doctor? What benefit would I have my calling up a doctor, pissing them off, and then not filling the script?

    You mainly refuse oxy unless it's from an oncologist... for the same reason I'd refuse oxy or adderall from a dermatologist. You and I are both deciding weather or not we fill narcotics based on SCOPE OF PRACTICE.

    You have made it clear that scope of practice in terms of law does not refer to specialties YET YOU PRACTICE AS IF IT DOES... further validating my point.
     
    Last edited: Mar 30, 2015
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  48. Lnsean

    Lnsean 7+ Year Member

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    I wasn't talking about medication standard of care or treatment guidelines or whether the drug is appropriate. I was talking about a dermatologist, when writing for an adderall script, is going outside of her standard of care. If you want to call it scope of practice; that's fine.

    When you are on trial and the prosecution examines you, they're going to ask you what is the standard of care as a pharmacist: would another pharmacist, in the usual course of his duty, fill this Adderall script written by a dermatologist. The answer would be no.

    Then it is a judgement that you have to make and defend. As pharmacists, we do this all the time. If you want to fill everything blindly, that is also your choice. You are a highly paid professional who's paid to make decisions; do your job and act like one.

    We're not obligated to look for the whole story. That is not our job. And what could the story be in this scenario? Do enlightment me.

    I was illustrating that documenting alone does not absolve you of liability. The problem isn't the quantity, but the fact that if you call these pain doctors they will give you a bogus dx code (like Chronic Pain Syndrome). This example was meant for OldTimer and other people who practice in retail. It went completely over your head. It's okay if you didn't get it since you work in a hospital setting.

    No, that's just you not understanding my original post. You're just making up things to rant about to sound intelligent. All I've said is that we can use our judgement and make a decision; we're not bound to fill every script blindly.
    Right, because working in a hospital setting, you already know that and understand what these medications and under what circumstances they are being written for. It's the same judgement that we apply to retail, only with different result because it is a different practice setting....whooshhh
     
    Last edited: Mar 31, 2015
  49. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    Holy contradictions paragraph to paragraph!
     
  50. npage148

    npage148 Senior Member 10+ Year Member

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    Since these threads and multi year bumps are fun.

    I had a dentist argue they should be able to prescribe doxy to their daughter to treat suspected Lyme becaue it can affect joints and the jaw is a joint. He also claims he didn't know his scope was restricted. Sigh.

    To make matters worse. The old pic filled all things for him, cipro, ery eye oint, lidex cream, etc.
     
    Last edited: May 30, 2017
  51. sosoo

    sosoo 7+ Year Member

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    i had a phone in refill for Tamiflu. i wasn't sure why the previous pharmacist filled it with multiple refills. so i check on the doctor. he's a cosmetic surgeon from the other side of the country. and yea its a cash paying. it amazes me the incompetent level of my PIC.
     
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