Prescribing Process (Clinical)

Some of the preamble appears in a gm-devel thread

To prescribe is to advise (e.g. a medicine) especially by an authorized (written) prescription. So at an encounter and its components (encountlets) we have the possibility of a treatment plan with many elements. Some will be simple things the patient can do by themselves e.g. lifestyle change, over-the counter medicine which do not require any "authorization" by the doctor. Yet we can argue a value to being able to print the entirety of a patient's current treatment plan including those things that do not require the doctor's authorization. So we have a hierarchy of

Treatment plan elements (further described here)
  • treatments that the patient can do on their own
    • can include non-prescription drugs!
    • can of course include non-drugs
  • treatments that require a "prescription" (doctor authorization)
    • non-drug items
    • drug items

In the prescribing of medication:

  • first, the clinical problem ("indication") to be treated is identified
  • next, possible interventions (including drug therapies) are considered
    • these are identified from memory, and/or are supplemented...
    • using print or online guidelines and recommendations

When drug therapy is (or may be) appropriate, prescribing steps may include:

  1. review of current & prior drug history
    • are they already under treatment?
    • what (if anything) have we tried before?
  2. review allergy & intolerance info
    (info may originate from care given by others, if accessible)
  3. consult guidelines for medical condition
    • are there drugs of choice?
  4. check comorbidity (problem list) for pertinent items
    (these may factor "for" or "against" candidate drugs
  5. select drug based on above plus gestalt of
    • safety / tolerability (adverse effects)
      (patients need to be advised)
    • drug interactions
    • cost, benefits coverage, & whether affordable; may include
      • ascertainment of eligibility for specific drug(s)
      • procedural requirements for authorization (forms procurement, completion, submisison etc.)
  6. identify whether any samples can/should be given
  7. identify whether a prescription is required (vs over-the-counter options)
  8. decide prescription information ("formula"?)
    • select drug strength (cost considerations can come into play for pills that can be split)
    • select drug form (duration of action, convenience, tolerability)
    • specify whether to "do not substitute" (DNS)
      (a consideration when generics may not be interchangeable)
    • decide amount to supply
      • arbitrary calculation of amount if is to be "taken as needed" (pro re nata or prn)
      • benefit policies can limit maximum amounts that can be dispensed
      • where permitted, decide whether to authorize any refills, depends on
        • timing of when the problem (or response to drug) should next be assessed, and
        • can depend on policies (e.g. drug-specific, country specific e.g. some prohibit "refills")
  9. repeat for each medication that is
    • to be initiated OR renewed OR
    • to be altered AND requires additional supply
      (otherwise no prescription event happens)
      (also no prescription event for medications stopped)
      (all extant renewals remain available)
  10. print / submit prescription

See PrescribingReports for info about prescriptions and other reports

-- Author JamesBusser - 15 Mar 2005

--- This topic: Gnumed > WebHome > PrescribingInterface > PrescribingProcessClinical
Topic revision: 30 May 2005, JamesBusser
 
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