• A prescription must be neat and legible. This point has become a cliché but that does not diminish its importance. No one is insisting that a prescription be a model of calligraphy but the ink and the handwriting must be clear and decipherable.
• The prescription must be written on a letterhead so that the doctor can be identified and contacted if clarifications are necessary.
• The prescription must have a date.
• Patients identification information must be complete. This implies that the full name and the postal address of the patient be noted down along with age and sex.
• Abbreviations are to be used as sparingly as possible. In particular, non-standard abbreviations and latinizations should be avoided. In institutional settings some abbreviations are used ¾ these should be standardized and intimated to all new staff. But drug names should be spelt correctly and should not be abbreviated.
• Brand names, if specified must also be spelt correctly. This is vital since entirely different drugs may have similar sounding brand names.
• It is preferable to write the word ‘Units’ in full ¾ an ‘U’ can be read off as ‘0’ leading to a ten-fold increase in dose!
• A decimal number less than 1 should always have a leading zero e.g. writing 0.5ml rather .5ml. On the other hand a zero alone should not follow the decimal point e.g. writing 1 ml instead of 1.0 ml. Missing a decimal point can have catastrophic consequence. The best option would be to avoid unnecessary use of the decimal point e.g. writing 500 mg instead of 0.5 g.
• Prescribing by generic / non-proprietary versus brand / proprietary names is a matter of perpetual controversy. Generic prescribing has several advantages. However, one may need to use a brand name if prescribing a formulation with multiple active ingredients or if the drug has critical bioavailability so that indiscriminate brand changes are not advisable. Some doctors also use brand names to be sure of the quality of medication being received by the patients. If a brand is specified it becomes imperative for the pharmacist to dispense that brand and not substitute another at will.
• The exact number of the doses or the exact duration of the drug use should be specified rather than leaving the patient and pharmacist guessing as to the quantity that should be dispensed. This, however, does not apply to items to be used as required.
• The dosing frequency and the timing of drugs with meals, if any, should also be specified unambiguously. These matters often cause considerable unnecessary worry to the patients and their relatives.
• Special instructions for the pharmacist, if any, should also be written down explicitly rather than depending upon patients to convey them
• The prescription must always be signed.
• It should be revised after writing.
• Finally, the prescription must be explained clearly to the patients or their attendants. This is all the more important in India as prescriptions may not be written down in vernacular languages or the patients may be illiterate. The doctor must be sure that the use of special formulations, for example dispersible tablets, has been correctly understood by the patient.

What are the factors that hinder good prescription practice (GPrP) in India? The reasons are not difficult to discover:

• Doctors in training or new in practice tend to copy the prescribing habits of their peers rather than developing good prescribing practice on their own. On their part, senior doctors are often hard pressed for time to write out a proper prescription. The situation in public or charitable hospitals is most acute in terms of patient load, with the result that prescriptions are scribbled out in a hurry leaving the patients to cope as best as they can with illegible slips of paper. Clinical notes, tests recommended, investigation findings and drugs prescribed are all jumbled up together. Refilling instructions are often absent.
• Prescribing by brand names has become second nature to Indian doctors, particularly in the private sector, despite the confusion that results. It is not uncommon to find a second doctor failing to understand the medication history of the patient because he or she fails to recognize the brands prescribed by the earlier doctor and even putting the patients on courses of the same drugs, albeit under different brand names, to which they have not responded or have had adverse reactions to, earlier.
• The majority of ‘pharmacies’ and ‘chemist shops’ are often run by individuals without even a modicum of knowledge of chemistry or pharmacy, leave alone being staffed by a qualified pharmacist. The result ¾ drugs prescribed by generic names are not recognized, improper brand substitutions are made and proper drug usage is rarely explained to the patient.
• The huge array of formulations and sheer number of brands in the Indian market is a source of considerable confusion. As one example, more than 80 brands of ciprofloxacin are currently available. The competition leads to unethical promotion and unscrupulous trade practices. Generally higher priced brands mean greater profit margins for the retailer. So your neighborhood chemist is not likely to stock too many lower priced formulations or may not honor a generic prescription by dispensing such a brand ¾ this defeats the economic advantage of generic prescribing. There is also the possibility that spurious or poor quality products may be dispensed.
• Patients are indifferent and often unaware of the fact that it is important to understand their own prescription. They fail to ask the doctors for repeat instructions when they do not understand or are too overawed to question the doctor. Doctors sometimes are arrogant too and do not consider it part of their professional duty to explain drug usage properly to the patient.
• Inadequate legal checks and balances serve as disincentives to GPrP. There are also no national guidelines on good prescription writing or institutional efforts to promote the same.
• Last, but perhaps the most important, is the tremendous amount of ignorance and indifference regarding the need for GPrP, which has led to this dismal situation in India.

Undeniably, some time and effort needs to be expended in framing a proper prescription. Taking a shortcut at the patient’s expense is not good practice. Physicians must discard the ‘I don’t have time’ or the ‘why bother’ attitude and take the initiative on their own rather than being forced by a legal instrument, such as the Consumer Protection Act, to develop good prescribing practice. A well-written and well-understood prescription goes a long way in improving patients compliance and in building up the patient’s confidence in the doctor. This can spell the difference between success and failure of therapy.
Avijit Hazra

References:

1. Prescription writing. British National Formulary 1998; No. 35 (March, 1998): 4-6.
2. Ansel HC. The prescription. In: Gennaro AR, editor. Remington: The Science and Practice of Pharmacy. 19th ed. Easton, Pennsylvania: Mack Publishing Company; 1995: 1808-21.
3. Benet LZ. Principles of prescription order writing and patients compliance instructions. In: Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Gilman AG, editors. Goodman & Gilman’s The Pharmaco-logical Basis of Therapeutics. 9th ed. New York: McGraw-Hill; 1996: 1697-1706.
4. De Vries TPGM, Henning RH, Hogerzeil HV, Fresle DA. Guide to Good Prescribing: a Practical Manual. Geneva: World Health Organization - Action Programme on Essential Drugs; 1994.

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