Residents Writing Prescriptions

[SNUFFYLOVE]

I am a pediatric resident and have written many prescriptions for albuterol and the spacers and masks via computer but have never written them by hand and am concerned about going out "in the real world" and writing these prescriptions correctly. Can you wonderful pharmacists please tell me the appropriate way to write an albuterol prescription (both neb and MDI) and a presciption for the spacer and mask?

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[Carboxide]

My preferred way of writing those would be:

Albuterol: Inhale 1-2 puffs q4-6h prn for wheezing/SOB. Use with spacer
Spacer: Use as directed

 

[rx2010]

For the nebulizer vials, just put 1 vial tid-qid prn. We know it's through a nebulizer, so you really don't have to put it in the directions. Also, please state which size box you want to dispense, they come as a box of 25 vials and 60 vials. Most physicians just write something like dispense 1 box and we have to call and ask which size they want.

 

[Hope1974]

For the nebulizer vials, just put 1 vial tid-qid prn. We know it's through a nebulizer, so you really don't have to put it in the directions. Also, please state which size box you want to dispense, they come as a box of 25 vials and 60 vials. Most physicians just write something like dispense 1 box and we have to call and ask which size they want.

Doctors never state what size box they want dispensed. In all my years in the pharmacy I have never seen that, there are too many, and different chains tend to carry certain ones. For example CVS always had the smaller boxes of albuterol whereas the chain I work for now has those, but mostly the larger boxes of 180.

All the doctor as to write in addition to the sig is the number of vials, i.e. # 25, meaning 25 vials. We give the quantity of boxes according to the closes number the doctor stated. For example if the doctor writes #35 meanng 35 vials we would give the box with 30 vials or, if we carried the 25 vial boxes we'd give them one of those. We wouldn't give 2 boxes of 25= 50 vials, because 35 is closer to 1 box= 25 than 50.

 

[Hope1974]

If you're at a slow store you can find time to call on what size box (really who does that)? But if you have 180 calls in a busy store, with 2 techs, and 1 cashier and 180 scripts to verify at 10:00am due to a call center list, and every second person wants to wait for their medication, well then I would concentrate on more important calls.

If doctors would simply write more clearly on scripts, especially when it comes to writing their first and last names on scripts from hospitals, or be aware of medications that are most likely not covered by insurance, or medications that are too costly (i.e. antibiotics that a patient won't buy or complete the regimen) it would save us pharmacists a lot of time.

 

[Dr Wario]

I just wanted to show my appreciation for your asking the question. I would also like to emphasize what has already been said about clearing writing your name (we are not allowed to simply put your facility) and try to write somewhat legibly. It is difficult enough trying to clarify a rx written by a practice, but trying to track down a resident in a hospital when you cannot even read the signature is almost impossible.

More specifically to your question concerning inhalers, please never write for Xopenex as 70% of insurance companies will not cover this without a prior authorization. Oh and please do not write directions like "inhale 1 vial via vaginal rout six times a day at bedtime".

 

[All4MyDaughter]

Please make sure your name is legible somewhere on the script. If you scribble your signature, either circle your name at the top of the blank (so we know who to pick off the list) or print your name under your signature.

If you are using an institutional blank, please give us a phone number where we can reach you. I spent WAY too long today tracking down a hospitalist who used a University Hospital blank with no phone number... the switchboard was suprisingly unhelpful and the office number they provided was wrong.

 

[ethyl]

kudos to the resident for asking this question. You'll certainly help your patients by avoiding delay of treatment due to office calls or insurance issues. Writing for the how many vials to use, frequency and total quantity of vials will help for the neb.

Writing for MDI albuterol can be tricky depending on insurance. I suggest never writing for a brand name albuterol inhaler. Certain insurance companies prefer certain brand name inhalers. A pharmacist isn't supposed to automatically substitute Ventolin for Proventil because they're not considered equivalent to the FDA's Orange Book.
The preferred writing for an albuterol MDI to avoid insurance issues is just writing the generic name.
Albuterol MDI #1
2 puffs every 4 to 6 hours PRN

 

[ethyl]

As for the spacers, just write for a spacer as a different prescription.
Spacer with infant mask to be used with albuterol MDI #1
If a mask is needed, feel free to specify the size. (Infant or child). Otherwise the pharmacist will fill for whatever they think will fit. Writing for this kind of 'generic' spacer will allow the pharmacy to fill for whatever spacer they may be carrying. If you write for a brand name like, EasiVent spacer, the pharmacy may have to order it and delay treatment another day (or up to 3 days if it's a Friday).

 

[rx2010]

Doctors never state what size box they want dispensed. In all my years in the pharmacy I have never seen that, there are too many, and different chains tend to carry certain ones. For example CVS always had the smaller boxes of albuterol whereas the chain I work for now has those, but mostly the larger boxes of 180.

All the doctor as to write in addition to the sig is the number of vials, i.e. # 25, meaning 25 vials. We give the quantity of boxes according to the closes number the doctor stated. For example if the doctor writes #35 meanng 35 vials we would give the box with 30 vials or, if we carried the 25 vial boxes we'd give them one of those. We wouldn't give 2 boxes of 25= 50 vials, because 35 is closer to 1 box= 25 than 50.

Yes, you're right. I meant to state how many vials they want to dispense, not the box size.

 

[AminoAcid777]

Also, don't forget to specify strength if it is a nebulizer solution. 99% of the time it will be 0.083%.

Thanks

 

[Farmercyst]

Don't forget to sign the thing. I had 2 ER docs on Sunday who forgot that part. One of them twice...on controlled substances no less.

 

[peacewalker]

Great points made in this thread! My most common needs to contact a doctor/hospital (and thus wasting both your time and mine) in regards to this area are:

1. Cannot tell which MD wrote the prescription (please write your full name legibly)
2. No qty written on the Rx, (please just write how many vials you want dispensed to avoid discrepancy)
3. Clarify strength of the solution

 

[kvl1027]

Great points made in this thread! My most common needs to contact a doctor/hospital (and thus wasting both your time and mine) in regards to this area are:

1. Cannot tell which MD wrote the prescription (please write your full name legibly)
2. No qty written on the Rx, (please just write how many vials you want dispensed to avoid discrepancy)
3. Clarify strength of the solution

I am just thankful that you are asking the question. We should have an entire forum dedicated to how we can help physicians and how physicians can help us in terms of getting the patient what they need, without having to call for clarification.

 

[AminoAcid777]

I am just thankful that you are asking the question. We should have an entire forum dedicated to how we can help physicians and how physicians can help us in terms of getting the patient what they need, without having to call for clarification.

Great idea! I second that! I bet medical residents have tons of questions they would like to ask us and vice-versa!

 

[spacecowgirl]

My request is to put a PRN reason. It's just a good habit to get into. Auditors get a bit touchy at the SNFs and hospitals about range orders and PRNs without parameters or indications.

 

[kvl1027]

My request is to put a PRN reason. It's just a good habit to get into. Auditors get a bit touchy at the SNFs and hospitals about range orders and PRNs without parameters or indications.

Yes, PRNs without parameters and "use as directed". The insurance companies will audit us every time, especially on more expensive medications.

 

[spacecowgirl]

Oh yes, insurance companies too. I don't work retail often so I forget about that aspect.

 

[007rx]

I don't even know you, SNUFFYLOVE, but I am pretty sure you are an awesome person. Your post made me happy. I also agree that we should have a thread just for basic prescribing tips to make things so much smoother for all parties involved. So another handy tip is that sometimes parents want to have several inhalers (i.e. one for the child to keep at school, one for the mom to put in her purse when they are out and about, etc) in the event they forget one and the child is having wheezing/SOB (so they can have a backup). So if you write for the child to have #2 inhalers on the script, some insurance plans allow for several to be filled simultaneously for this very reason.

On a side tangent, I see so many patients come in who can't afford their or their children's asthma medications because pretty much everything is brand name only at this point in time unfortunately, except theophylline lol. They are using their albuterol inhalers on a scheduled basis (not as directed) because they can't afford the expensive corticosteroids. I'm talking $50-75 per month, which may not be expensive to us but to them it is. Please refer them to the manufacturer's website for coupons/patient co-pay cards. That message goes out to everyone, be it pharmacist/student/resident/physician. The manufacturers of a few medications (which I probably can't get too specific since it would probably violate the terms of service) have some coupons on their website that your pediatric patients' parents can print off and save them some money on their monthly co-pays. It really helps out with adherence, which usually improves outcomes. Let's just say one of them is a leukotriene receptor antagonist and the other is a dry powder corticosteroid/long-acting beta-2 agonist available as a dry powder or an inhaler. Do some research, and good luck with future prescribing 🙂

 

[owlegrad]

I don't even know you, SNUFFYLOVE, but I am pretty sure you are an awesome person. Your post made me happy. I also agree that we should have a thread just for basic prescribing tips to make things so much smoother for all parties involved. So another handy tip is that sometimes parents want to have several inhalers (i.e. one for the child to keep at school, one for the mom to put in her purse when they are out and about, etc) in the event they forget one and the child is having wheezing/SOB (so they can have a backup). So if you write for the child to have #2 inhalers on the script, some insurance plans allow for several to be filled simultaneously for this very reason.

On a side tangent, I see so many patients come in who can't afford their or their children's asthma medications because pretty much everything is brand name only at this point in time unfortunately, except theophylline lol. They are using their albuterol inhalers on a scheduled basis (not as directed) because they can't afford the expensive corticosteroids. I'm talking $50-75 per month, which may not be expensive to us but to them it is. Please refer them to the manufacturer's website for coupons/patient co-pay cards. That message goes out to everyone, be it pharmacist/student/resident/physician. The manufacturers of a few medications (which I probably can't get too specific since it would probably violate the terms of service) have some coupons on their website that your pediatric patients' parents can print off and save them some money on their monthly co-pays. It really helps out with adherence, which usually improves outcomes. Let's just say one of them is a leukotriene receptor antagonist and the other is a dry powder corticosteroid/long-acting beta-2 agonist available as a dry powder or an inhaler. Do some research, and good luck with future prescribing 🙂

Haha, in this case I think it would be OK for you to name them. 😉👍

 

[007rx]

Haha, in this case I think it would be OK for you to name them. 😉👍

Asmanex, Advair Diskus/HFA, Alvesco, Dulera, Foradil, Proventil, Singulair, Symbicort all have manufacturer coupons available that can save patients anywhere from $10-75 per month. Some of them even have a free trial. Google "internet drug coupons" and there's a website available that has all of these available to print off for your patients and you can leave a stack by your technician's computer. Again, I have no conflicts of interest except for making prescriptions more affordable for patients 🙂

 

[farmadiazepine]

Please don't write for Xopenex inhalers or Xopenex for nebulizer .. Like a previous poster said either its NOT covered, or its a ridiculously HIGH co-pay, something that a parent cannot afford, so they decide not to get their child the rescue medication.

For albulterol inhalers, please write on the Rx "albuterol MDI" or "albuterol inhaler" .. Don't write a specific one (Proventil, Proair, Ventolin ... unless the patient really insists ... let them bring up that issue if its a concern) .. I always dispense Ventolin if its covered because its got a dose counter whereas the other 2 don't.

 

[Farmercyst]

Please don't write for Xopenex inhalers or Xopenex for nebulizer .. Like a previous poster said either its NOT covered, or its a ridiculously HIGH co-pay, something that a parent cannot afford, so they decide not to get their child the rescue medication.

For albulterol inhalers, please write on the Rx "albuterol MDI" or "albuterol inhaler" .. Don't write a specific one (Proventil, Proair, Ventolin ... unless the patient really insists ... let them bring up that issue if its a concern) .. I always dispense Ventolin if its covered because its got a dose counter whereas the other 2 don't.

Unless you're in CA where Xopenex is on Medi-cal's (CA Medicaid) formulary. 🙄 You wouldn't believe the daily number of calls to switch from Albuterol to Xopenex.

 

[farmadiazepine]

Hahhaha ... California, always gotta be out there