Emergency supply

Discussion in 'Pharmacy' started by mona2004, 05.17.14.

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  1. mona2004

    mona2004 2+ Year Member

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    I just want to know if a MD denied rx refill for celexa and pt appointment with new MD will be in a week is pharmacist allow to give pt 7 day emergency supply or not?
     
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  3. Aznfarmerboi

    Aznfarmerboi Senior Member 10+ Year Member

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    yes... It's up to a pharmacists professional discretion.

    I usually give what ever my customer needs as long as it is not a controlled.
     
  4. jafx

    jafx 2+ Year Member

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    Someone ought to report said doctor for not titrating their patient off a psych med before refusing a refill. Talk about dangerous.
     
  5. Ackj

    Ackj 7+ Year Member

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    So what are they to do? The patient doesn't show up for their appointments, you can't continue to authorize refills indefinitely. No valid doctor/patient relationship exists after a while.
     
  6. midweststudent1

    midweststudent1 2+ Year Member

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    I worked in a pharmacy for a couple years in college while I was pre pharm,....the pharmacists I worked with would never have given an emergency supply if the doctor had specifically denied the rx....sometimes the patient has to learn to responsibly manage their health, which know this case probably means actually following up to doctors visits
     
  7. genesis09

    genesis09 Senior Member 10+ Year Member

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    If the rx has actually been denied, than you shouldn't give an emergency supply. Patient should contact new physician and see if he/she will write for a one week supply. There is no guarantee that new MD will continue current medication. I never gave a week long emergency supply. My average is three days.
     
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  8. KidPharmD

    KidPharmD Pediatric Pharmacist 2+ Year Member

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    The state of Tennessee only allows for a 3 day supply while awaiting refill authorization (when such authorization is expected). After a refill was denied, no matter the reason, I would have never given an emergency supply.
     
  9. jafx

    jafx 2+ Year Member

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    Celexa isn't addictive. It's an SSRI; it's incredibly dangerous to abruptly stop taking it. I'm sure the malpractice lawsuit from the surviving family of a patient who blows their brains out after a sudden stop of their antidepressant would be just lovely.

    A man I went to church with in my twenties had been taking a number of antidepressants for a long period of time (10+ years,) his new psychiatrist assumed they were having no more effect on him and stopped treatment with those specific medications abruptly; prescribing new ones. Later that week he splattered his brains all over his truck.

    I personally don't think you can ever be too careful with psych patients.
     
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  10. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    I think in the face of a straight up order to not dispense, giving a 7 day supply operating under the assumption the new provider would continue it constitutes practicing medicine.

    The first MD is probably a moron for not titrating it down whether they're firing the patient or not. But moron or not, it's outside our scope of practice. It's inappropriate for us pharmacists to act under the assumption we know ALL of the facts in the case (we don't know what we don't know)...by filling it, we would put our trust in the patient story completely.

    Now, if the appointment was in a week with the same provider and no order to not dispense was received, then it would be appropriate. Part/most of our job is to infer a provider's intent, and in the OP's case, the provider's intent is to stop therapy...in the example in this paragraph, the intent is to continue until the next appointment (even if the official order says X refills).

    The OP should give the patient the phone number for their state's medical board and encourage them to file a complaint.



    Now...in the real world outside of this academic discussion on SDN, if this were an established patient with a good relationship with me/the pharmacy....I'd do him/her a solid and just top off their fill.
     
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  11. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    No, once a prescription has been denied, I would never give an emergency supply. The whole idea of giving an emergency supply is when you know a doctor-patient relationship exists and when there is every reason to believe that the dr will authorize refills once you contact him (but you can't contact her/him because its after hours.) Once you've contacted the doctor and s/he has denied refills for any reason, then there is no legal basis for giving an "emergency" supply.

    When faced with situations such as you have described, I have recommended the patient go to one of the several urgent care centers in our area--any of these are willing to give a months supply to a patient after evaluating them, when they are between physicians.
     
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  12. msweph

    msweph 2+ Year Member

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    I would not if the RX had been denied by the provider.
     
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  13. zelman

    zelman 7+ Year Member

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    No it's not.

    Tell them to take St Johns Wort for a week.
     
  14. jafx

    jafx 2+ Year Member

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    :wtf:

    You've obviously never titrated off an SSRI before if you really think St Johns Wort would be sufficient to replace a high dose of Celexa. Celexa is a b1tch to come off of.
     
  15. VCU07

    VCU07 Member 10+ Year Member

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    How do you know it was a high dose of Celexa? If the pt. had a few left and was denied another Rx, you direct them to start titrating off the drug. If the MD denied the Rx you can not give them an emergency refill. Its a pain, but call the doctors office and have then write for a quantity sufficient to at least allow for titration off the drug. If they deny that then you document it and have some legal proof in the case something happens to the patient. I had this happen to me as a new grad. We had faxed the doctors office multiple times about a SSRI. We received no answer for days (I had even called). Finally, they faxed back stating pt. was denied b/c they hadn't followed up for over a year. Sure enough, pt. had a seizure on the way out of the store. The retail place I was working for gave that young guy a really nice settlement (even though I don't think we were at fault here).
     
  16. SoylentGreen

    SoylentGreen 7+ Year Member

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    I don't see what's wrong with giving an emergency supply in the situation where the provider denies refills on the grounds that the pt needs to see a new provider. The point of emergency supplies is to give the patient time to get a new rx, and if they've been on a psych med for years, presumably they'll continue to be on one for years. If the provider denied the refill saying the patient shouldn't be on it anymore, that's a different matter.
     
  17. zelman

    zelman 7+ Year Member

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    Heroin is a bitch to come off of, but the withdrawal syndrome is not fatal. That's (one of several reasons) why I don't advance people a few oxys.

    Also, you shouldn't dismiss herbals as having no pharmaceutical effect, nor make assumptions about doses (of either agent in this instance).
     
  18. Ackj

    Ackj 7+ Year Member

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    I'm sure it would be quite a case as well when you're practicing medicine without a license. It could be denied for any number of reasons, not simply a missed office visit. Maybe the doc gave them samples of something new, some IM antipsychotic in the office, they had a reaction to the drug and that's why it's d/ced, etc. If the prescriber says "no, do not give them this medication" and you give it anyway, that's your ass on the line for whatever goes wrong. You can't trust what the patient says and just go by that either. Something like, "I had a reaction to citalopram, so my doctor stopped it, but I'm supposed keep taking my Celexa," however ridiculous, is easily something a patient can come up with.

    Even if it is just for missed appointments, you have to draw the line somewhere. You advance them a 5 day supply, they come back 5 days later, still no rx. You give them 5 more days? Here they are again on day 5. Are you willing to personally approve their therapy for an indefinite time? Even if you give them 5 days and tell them to titrate down, what if they came back and said they did not titrate, just took the full dose? They're out of meds again, what are you going to do?
     
  19. eagles22

    eagles22 5+ Year Member

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    This is all based on the fact that this patient has been compliant with his/her treatment. What are the odds that someone who is presumably not following up with his doc is also taking the med every day? He may not even withdraw if he's only taking it sporadically.
     
  20. BenJammin

    BenJammin No Apologies 5+ Year Member

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    The 72 hour rule is designed to avoid the slippery slope of pharmacists trying to practice medicine. If the doctor hasn't called back or it's the weekend and they're unable to authorize refills then give them the 72 hour quantity or as determined by law. NOTHING ELSE. Giving a 7 day supply is practicing medicine without a license. If you give them the 3 day supply and you still haven't heard back from the doctor, where does the malpractice lie if there is negligence? The prescriber.
     
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  21. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    Because there is probably a reason the prescriber is no longer taking care of the patient....did the patient get mad because s/he didn't like the prescribers advice and decide to stop seeing the doctor? Then its the patients own fault if they run out of med. Is the patient unwilling to submit labwork and visit the physician.....then, or course, the physician would deny refills, how can s/he know what is going on with the patient and know whether or not the Celexa refill is appropriate? If there is some huge liability with the withdrawal, the physician is going to be first to be sued, and the physician knows this, so if in spite of this, the physician still feels it is most appropriate not to renew that patients prescription, there is no way I am going to risk my license by giving them a prescription medication when the patient has no prescription. I am not equipped to examine the patient and determine if they need this medication.

    Especially since, at least in my area, there are several urgent care centers that will give 1 month supplies of maintenance meds AFTER examining a patient....it a patient isn't willing to go to the urgent care center, then that is just more evidence that the original doctor was correct in denying their refills, and I am correct in refusing them an "emergency" supply.
     
  22. jafx

    jafx 2+ Year Member

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    Thank God pharmacists have not-so-limited prescribing power where I live.
     
  23. jafx

    jafx 2+ Year Member

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    This is really quite good advice. Perhaps one of the most logical and level headed responses to this thread I've read.
     
  24. Gombrich12

    Gombrich12 2+ Year Member

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    It depends on the state. Some states it is 7 days, others it is 30 days, and some 72 hours. Know your local laws.
     
  25. owlegrad

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

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    I agree with those that have said no way. Why would I give some one something that the doctor said no to?
     
  26. Digsbe

    Digsbe 5+ Year Member

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    I wouldn't give an emergency supply if the prescriber specifically said they wouldn't refill it. It would be unethical medicine to not titrate the patient off first, but I still wouldn't fill it if the prescriber wasn't going to authorize additional fills and specifically said they wouldn't. The principal behind the emergency refill is to make sure the patient has meds while awaiting a refill authorization from the prescriber all done in good faith (no reason to believe that they will be discontinued, usually done for maintenance meds). I think it violates the purpose behind legally allowed emergency supplies to give out medications when the prescriber has specifically said that they will not refill fore that patient and they'll need to see a new provider.
     
    Last edited: 05.18.14
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  27. maria1oh

    maria1oh 7+ Year Member

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    Generic celexa is cheap. No big loss to employer to give out 7 tablets. I work in HIV areas and have issues with people wanting me to give out emergency supplies on HIV meds that say you are suppose to dispense in original container and cost thousands per bottle.
     
  28. BidingMyTime

    BidingMyTime Lost Shaker Of Salt 10+ Year Member

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    the cost of the drug is irrelevant, we are talking about the legality of it.
     
  29. pharmacy7424

    pharmacy7424 Banned Banned

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    In PA the law says that you may give a 3-day emergency supply if it is at your discretion.
    Regardless of the consequences if you do not give the emergency fill, I do not believe there is any liability that you can be accountable for if you refuse an emergency fill for any reason (in PA), due to the law's use of the word may.

    Somebody correct me if I am wrong.
     
  30. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    I think you're replying to a discussion that doesn't actually exist.
     
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  31. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    Yeah I think you're right...the word may is very much different from shall/will which indicates you are compelled to dispense an emergency supply by law.

    It's at your discrection, but it becomes a liability issue on your part. If your actions directly contravene a physician's valid order to NOT dispense a drug, it can be argued that your actions were practicing medicine. So yes, you wouldn't run afoul of the law regarding discretion in dispensing a drug, but you WOULD run afoul of other regulations governing the practice of medicine.

    It's like law A says "you may speed on the freeway to get away from baddies chasing you" but in order to do so, you have to open up the throttle on your car and now you run afoul law B that says "you cannot make loud ass sounds in this neighborhood."
     
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  32. owlegrad

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

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    What state allows for a 30 days supply? Why would anyone give that many?
     
  33. zelman

    zelman 7+ Year Member

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  34. Aznfarmerboi

    Aznfarmerboi Senior Member 10+ Year Member

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    I practice in NY. I have not seen any law saying that I may not give a 7 days emergency supply. I dont see any problem here because the intent is good....

    I believe it is up to a pharmacist's professional discretion. I am not saying it is legal. I am also not saying that it is illegal unless stated by your BOP. What makes a pharmacist a professional is their ability do things upheld by a standard that is based on ethics in addition to their skill sets.

    There are a million situations, and in this case, if the doctor is discontinuing a SSRI that should not be stopped abruptly because there was no follow up for a year, and it takes the customer a week to find a new MD (not unreasonable in today's modern medicine), I think it is okay to give the customer a week's worth if they have been on this medicine for a year.

    If you know of any BOP who prosecuted a pharmacist who has an intent in looking out for the patient, I would love to know about it.
     
  35. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    Intent is irrelevant here. If someone came crawling into your pharmacy, writhing in pain, giving him 800 mg of Motrin is good intent.

    I think you're too focused on the BOP and forget that there's a whole separate/distinct category of laws we're implicitly discussing here. In NY, it's specifically Article 131, Section 6521-6522. At what point do we depart the realm of professional discretion/BOP jurisdiction and venture into the realm of unlawful practice of medicine/board of medicine territory? The line is never distinct.

    I'm probably repeating myself, but any BOP is silent on this because it's not in their scope/jurisdiction to govern acts considered medical practice.

    You/other posters in this thread make the assumption this is the case. Nowhere did the OP mention this as the reason (unless I missed it somehow). All we know is a patient waltzes into the pharmacy claiming they are out of pills and seeing a new physician in a week, and we have a distinct order to NOT dispense the medication to the patient.

    Putting it bluntly... it's not our legal right/practice to make up for what we consider moronic prescribing practices when we receive a distinct "no" for an answer.

    Example: I was rebuffed by a prescriber who ordered fluconazole for a mycelial fungal infection. Moronic, but what was I going to do, send down some vfend instead?


    Probably zero, but this isn't the point. That and I'm too busy to look. I'll punt that to the next person that replies.:whoa:
     
  36. Gombrich12

    Gombrich12 2+ Year Member

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    North Carolina is one state that allows for a 30 day supply. Also their rules state you must send a notice to the doctor within 72 hours saying you gave an emergency supply.
     
  37. confettiflyer

    confettiflyer Did you just say something? 10+ Year Member

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    I wonder what the prescriber would say in the OP's situation, and how the pharmacist would explain that one.

    RPh: "Welll.....the doctor said no, the pt couldn't have it....but he's a moron so I gave 30 tablets to the patient anyway. That constitutes an emergency, right?"
     
  38. owlegrad

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

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    Oh yes, the "mercy pack" is how I have heard that described.
     
  39. KidPharmD

    KidPharmD Pediatric Pharmacist 2+ Year Member

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    The state of Tennessee has revoked a license for excessive "emergency supplies" under the label of "dispensing without a prescription" The two pharmacists I know of surrendered their license "voluntarily" to keep the official description out of the meeting minutes of the board of pharmacy.
     
  40. jafx

    jafx 2+ Year Member

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    Hmm... Tennessee... how much you want to bed that was for *emergency* oxy? ;)
     
  41. owlegrad

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

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    You know two different pharmacists who surrendered their licenses due to excessive emergency supplies? I am curious what the circumstances around that were?
     
  42. npage148

    npage148 Senior Member 10+ Year Member

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    What really bugs me is when a patient SHOULD have been out of meds for 2 weeks and then starts demanding an emergency supply.

    my emergency supply criteria to get a 3 day supply of meds
    1. requesting the supply within 2-3 days of being out of medication if taking appropriately. Not requesting early or 2 weeks after the fact
    2. not denied by prescriber (have had to do this several times)
    3. the medication is something that needs to be indefinitely continued (no IBU etc)
    4. been on the medication chronically
    5. not a CS
    6. we, as a store, are on good terms with the patient.

    In NY i'm not obligated to give an emergency supply and when I do it's a courtesy to keep you from wasting your day at the ER getting a script
     
  43. Aznfarmerboi

    Aznfarmerboi Senior Member 10+ Year Member

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    I don't see giving a weeks worth of meds to hold a customer over practicing medicine. We can take any situation and go either way with it.

    I am also not disagreeing with you..., I would not give a patient waltzing into my pharmacy claiming they are out of pills if I do not know who they are. Nor would I give 800 mg of ibuprofen for somebody in pain.

    and that is why we are professionals. We should be able to decide what is right or not. That is the point that I am trying to make.

    In the old days, most pharmacists have no problems doing this. Independent pharmacists want to look out for their customers.

    Also, keep in mind that a lot of people put too much thought into things. For example, when a doctor denies a refill, it only means they are not taking responsibility for the patient and thus can not give them x amount of supplies. It does not mean to NOT dispense the medication to the patient. If a doctor absolutely think that it is not okay to dispense a medication, they will say it a lot of times... ie DO NOT GIVE this medication because patient is experiencing side effects from it.
     
  44. Aznfarmerboi

    Aznfarmerboi Senior Member 10+ Year Member

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    Interesting. Can I get more information on this? Thanks.
     
  45. HouTX

    HouTX 2+ Year Member

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    in Texas, we're allowed to give up to 3 days. I'll use my professional judgement for 3 days only. if the governor declares a state of emergency, we are allowed to give up to 30 days. I have used exceptions before to give 4-5 days but it's an exception to the rule to my loyal, loyal customers that have extenuating circumstances
     
  46. eagles22

    eagles22 5+ Year Member

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    And if the doctor won't take responsibility for the patient, why would you want to do so? Not writing the rx implies that he does not want to give a medication. A doctor doesn't send every pharmacy a note saying what not to dispense, does he?
     
  47. doublehh03

    doublehh03 Senior Member 10+ Year Member

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    To add to your last point, when an MD denies a refill request, that means they want the patient to make an appointment (not necessarily having to actually go IN to see them) so they can charge the patient's credit card. I have several large practices here that do this, and more and more MDs are doing this to generate revenue. Pretty ridiculous, but they get away with it.

    To OP's point, outside of controls and non-maintenance meds, I am usually pretty nice about this. You judge based on their past RX history, how well you know them, and how likely the refill request will be authorized. If a patient has a history of always needing "loaners," then you definitely should put your foot down and say hey, do you part and go to the appointment. If it's once or twice needing some Diovan for an elderly person b/c they couldn't make their appointment on time, you seriously would deny that?

    Or you can offer to call the MD and ask to see if they can authorize a week supply of RF and put in the sig, must see MD for further refills.
     
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  48. DrBowtie

    DrBowtie Final Countdown Moderator Emeritus 10+ Year Member

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    This thread is very interesting from a prescribers perspective. Goes to show we all need more cross profession education.
     
  49. HouTX

    HouTX 2+ Year Member

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    care to give us prescriber's POV? sincere request!
     
  50. DrBowtie

    DrBowtie Final Countdown Moderator Emeritus 10+ Year Member

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    Denying a refill request isn't a vindictive punishment for the patient as some are painting. I can list a few common situations:

    1. Post hospitalization discharge med script. A hospitalist or other exclusively inpatient provider initiates a new medication while patient is hospitalized and gives patient a script for varying length of time based upon provider comfort. After discharge the clinical relationship is terminated and responsibility is shifted to the outpatient doctor. The inpatient doctor will usually not refill as they aren't following pertinent labs or able to gauge symptomatic relief. It is up to the patient and outpt provider to decide if it should be continued and new long term script should be written.

    2. Pt is on long term DM or HTN meds. There are certain clinical standards of care that must be met ie foot exam, eye exam, UA that must be done yearly and documented. These measures are going to be tied to reimbursements in the near future. Having finite limits "force" patients to return to office for re-eval to make sure things aren't progressing and patient is compliant.

    3. The patient is partly responsible for knowing their med situation. Once they fill their last refill at the very least they should make an appt or call for a new script. It should never be a surprise to run out of a chronic med. The compliant ones are good about this. The noncompliant ones aren't and the last thing I want to do is give a non compliant patient a longer leash without coming into the office for education/discussion.
     
  51. Digsbe

    Digsbe 5+ Year Member

    Joined:
    08.06.11
    Messages:
    1,006
    Status:
    Pharmacist
    Under the legal provisions behind giving emergency supplies it is still illegal to give out controlled substances. Regardless of refill request or not pharmacists cannot give emergency controlled medications the same way they can for non-controlled. It's all subject to professional judgement which can be regulated by the board.
     

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