Prescription Writing is a daily chore for all Clinicians, however we hardly ever try to excel in it’s format and detailing, because hardly anyone appreciates our dedicated efforts. Pursuit of Excellence is simply not a default Indian Trait . Any style is okay for everyone concerned.
Whether Hand-Written or Computer Software generated, the difference is only cosmetic and more trendy solely for the Customer who receives it.
Let’s focus on the essential elements and vital yardsticks of a Good Prescription .
In a true sense, I need to stress here that, any third party should be able to draw enough conclusions – related to the illness and our diagnosis + therapy , by carefully reading and evaluating our Prescription, from multiple angles.
The ACUMEN and CLASS of any Clinician is best judged by his Prescription . An experienced Doctor who delivers a suboptimal / lousy / Incomplete Prescription is indeed an ugly combination.
Building our image in the Society can be best achieved by two things : Counselling Skills and the Prescriptions issued by us. Everything else hardly ever matters.
Elements of an Optimal Prescription
The Full Name, Age ( + DOB ) Body Weight / Height of the child patient and general appearance is for record keeping.
The Presenting Symptoms in local language has to be recorded and documented. Clinical Notes to be mentioned, after a complete Clinical Examination. Details of Lab Reports that are relevant to substantiate our Diagnosis are also mandatory to note .
Initiatially a Provisional Diagnosis at first consultation and thereafter a Final Diagnosis is a cardinal feature of an ideal Prescription.
The number of Oral Medicines should not exceed 3 or 4, with the FIRST ONE penned be the most relevant to the diagnosis ( say, the Antibiotic ) Symptomatics to then follow and the Topical Preparations – as the last ones.
Advice delivered and Counseling done should be documented in the prescription.
Injectables given for quick relief and Procedures done should be displayed in the document, fetching space even on the back side of the Prescription.
Any advice regards Hospitalization and other Interventions ( whether rejected or accepted ) should be highlighted, as a legal safeguard in the hostile society milieu that prevails around us.
As we enter a new ERA of Litigations from our clients and the Establishment ( under various Regulations and Ordinances – even at OPD LEVEL ) , our Prescription needs to be displaying these simple features :
Clarity and Readability
Ample justification for our Diagnosis, Therapy and Counseling
Evidence based Approach
Detailing of all minor elements in the Write-up
Warm regards and an open invite for feedback / comments
Wishing you Careful Prescribing Practices