For each section of the chart, you need to fill in the date, the generic name of each drug, its dose, how frequently it should be prescribed and your signature and bleep number. Abbreviations for prescribing are shown in Table 10.1.

Tips for filling in drug charts

• Write legibly. Other people have to administer drugs that you prescribe. Slips of the pens can have huge consequences. Capital letters are often best.
  
• In particular, take care in writing dose amounts and units. Micrograms (abbreviated mcg or μg) can easily be mistaken for milligrams (mg); the BNF advises that ‘micrograms’ and ‘units’ be written in full. (A doctor was sued when a patient was given 125 mg of digoxin by a nurse who misread the scrawled ‘mcg’. She had to open many packets of the drug to give such a dose, so also ended up in the dock for failure of common sense.) Using ‘u’ for ‘units’ is also very susceptible to be misread as an additional zero, which can have disastrous consequences. Putting a dot in the middle of the U is a common but not reliable way of attempting to make this practice safer.
  
• Develop a good relationship with the ward pharmacist. They are there to help you! They review all drug charts, albeit often after the drug has been given a number of times, and will usually bleep you if you prescribe anything idiotic – this is something you should encourage! Similarly, experienced nurses, who administer many drugs, will usually let you know if you have made a prescription error.
  
• Hospital pharmacists usually use green ink. To avoid confusion, use a different colour when writing on drug charts. Black pen is usually best.
  
• If drug administration is complicated, write legible additional instructions on the drug chart. There is no harm in writing extra notes to nurses and doctors on the drug chart. In fact it is legally advisable to do so. For some drug administration, hospitals have drug stickers that can be stuck into the drug chart to avoid confusion, for example, with sliding scales for insulin.

Writing prescriptions

FY1 junior doctors are only permitted to write prescriptions for the hospital pharmacy, so outpatient prescriptions and FP10 forms (green general practitioner [GP] prescriptions) shouldn’t be an issue. However, if you do need to write a prescription on plain paper the essential ingredients are:

• Date
  
• Name of patient
  
• Patient’s date of birth
  
• Address of patient
  
• Generic drug name and amount
  
• Dose/day
  
• Quantity of tablets to dispense
  
• Your signature and printed name
  
• Your General Medical Council registration number

Controlled drugs

Prescriptions for take-home controlled drugs have to be written in a specific way; otherwise, the pharmacy will send the prescription back. This wastes a spectacular amount of time. To write a controlled drug prescription

the prescription must be in your handwriting – don’t use sticky labels. Include the following:

• Date
  
• Name of patient and their date of birth
  
• Address of patient
  
• Generic drug name and amount (e.g. ‘10 mg MORPHINE SULPHATE TABS’)
  
• Formulation of drug, for example, tablets or patches
  
• Dose/day
  
• Total number of tablets in both numbers and letters (e.g. ‘10/ten tablets’)
  
• Your signature and printed name

• For example:
  5/4/2014
  Mr TSD
  2 Tatelman Street
  Wolfchester WC5
  MST continuous tablets 10 mg
  20/twenty tablets
  10 mg twice daily for 5 days
  (Your signature and printed name)

Verbals

It is now legally suspect to prescribe drugs for patients ‘verbally’ over the phone to nurses. However, in certain instances it still occurs. Typical verbal requests might be ‘Mr Smith has a headache. Could he have two paracetamol please?’ The nurse writes your prescription in the drug chart, with a small note saying, ‘Dr X will sign this’. Verbals are fine for relatively harmless drugs, such as one-off doses of paracetamol or for doses of necessary drugs when you have been held up and coming to the ward is monumentally inconvenient such as a bag of maintenance IV fluids:

• Check your local hospital policy. Increasingly, verbals are not allowed by trusts. Some trusts only allow them if the medication is already prescribed and in use but a dose change is necessary. Verbals are NEVER acceptable for controlled drugs.
  
• It is important to sign verbal requests on the drug chart as soon as possible. Should any problems arise in the interim, the nurse who took the verbal is liable. Because of this, some nurses refuse to take verbals altogether and insist you come to the ward to sign the drug before it is given. This is a reasonable stance for a nurse to take, and you should think twice before you criticize it.
  
• Nurses will rightly usually refuse to accept verbals if they think the patient should be seen by a doctor before taking the drug. Whilst this can be frustrating, remember that nurses’ scruples provide a big safety net for you. Everyone remembers times when they were glad that nurses forced them to question what they were doing. Furthermore, blanket prescribing without thinking why that patient may be in pain or vomiting can be quite dangerous.
  
• Some hospitals allow a limited number of drugs (e.g. paracetamol, sublingual nitrate, lactulose, and antacids) to be prescribed by nurses after calling the duty doctor. Whilst you do not need to see the patient, it is prudent to check the reasons for the request. You may be required (depending on local policy) to sign for the drugs later.
  
• The bottom line is, if in doubt, quickly review the patient and make a decision on what to prescribe based on your findings. This will save you time overall, and you will be reassured that the patient is stable.

Drug infusions

Continuous infusions are easy to make up, but they are a complete pain at 4 a.m. Whilst it was traditional to make up midnight infusions like morphine, dopamine and glyceryl trinitrate (GTN) infusions before going to bed, this is now considered bad practice, and the advance preparation of medicines is frowned upon.

To make up an infusion

1. Find the vial of drug in the drug cupboard. Check the dosage and the expiry date, and ideally ask a nursing colleague to also double check.
   
2. Open the vial and draw up the drug into a suitably large syringe, usually 50 ml.
   
3. Draw into the syringe the required amount of diluent fluid. This is usually normal saline, sterile water for injection or 5% dextrose, drawn from unopened (sterile) containers.
   
4. Label the syringe with a large adhesive label. Specify the following on the label:
   
   
   
   • Date and time you made infusion up
     
   • Name of patient and DOB
     
   • Amount of drug in amount of diluent (e.g. 50 mg GTN in 50 ml normal saline)
     
   • Rate at which solution should run (e.g. 2 ml/hour)
     
   • Your signature and bleep