Unit 4 - Prescribing Partnerships

Documentation


'Poor records mean a poor defence and no records means no defence'
(Tingle, 1998).

Documentation and record keeping for prescribing is essential in order to satisfy legal requirements.
One of the biggest difficulties of prescribing is the sharing of information by patients and the healthcare professionals who need to know.

Reflection

Consider the wider picture. If medication is prescribed to a patient, which healthcare professionals must have access to that information?

Documentation and Patient Records for Independent Nurse Prescribing

The two NMC documents which provide the best guidance around documentation for independent nurse prescribing are:

NMC Guidelines for Records and Record Keeping (2005)
http://www.nmc-uk.org/(vo2j3jmaqtz4kuyl2zxifkeh)/
aFrameDisplay.aspx?DocumentID=516

NMC Guidelines for the Administration of Medicines (2004)
http://www.nmc-uk.org/(bvdem5aaiqms3faphcfwts55)/
aFrameDisplay.aspx?DocumentID=221

You may need to familiarise yourself with these updated documents. Remember, these are imperative to support your prescribing practice.

Reading

NMC Standards of Proficiency for Nurse and Midwife Prescribers (2006) lay out further guidance in Practice Standard 7.
http://www.nmc-uk.org/aArticle.aspx?ArticleID=2021

Further Reading

Further reading

Dion, X. (2001) Record keeping and nurse prescribing: an issue of concern? British Journal of Community Nursing 6: 4, 193-198.

Rodden, C., Bell, M. (2001) Record keeping is an integral part of nursing care. Scottish Nurse 6: 4, 32-33.

Developing a clinical management plan within supplementary prescribing

The clinical management plan (CMP) is a lawful requirement, and supplementary prescribing cannot happen without one.

The CMP is a patient-specific document. It must be drawn up as an agreement by the independent and supplementary prescriber, and endorsed by the patient. The CMP should enable the supplementary prescriber to manage the treatment and to prescribe for each individual within the defined parameters.

Information contained in the CMP must include the following:

  • Specification of the range and circumstances within which the supplementary prescriber can vary the dosage, frequency and formulation of the specified medicine
  • Specific guidelines of when to refer from supplementary to independent prescriber
  • Relevant warnings about known patient sensitivities and arrangements for notification of ADRs
  • Date of commencement of the arrangement and date for review.

As well as ensuring that each CMP contains all the required information, prescribers must adhere to the guidelines and standards laid down by their governing professional bodies — the NMC in the case of nurses and the Royal Pharmaceutical Society of Great Britain in the case of pharmacists

NMC Standards of Proficiency for Nurse and Midwife Prescribers (2006) lay out further guidance in Practice Standard 8.
http://www.nmc-uk.org/aArticle.aspx?ArticleID=2021

Template CMPs can be obtained from:
www.dh.gov.uk/assetRoot/04/06/84/28/04068428.rtf
or
http://www.cmponline.info

Refer Back

Link to 'Prescribing from patient group directions' and to 'The concept of supplementary prescribing' in the 'History and Background to Nurse Prescribing' section of Unit 1. Foundations of Prescribing Practice.

Make Notes

Look back at 'Prescribing from patient group directions' in Unit 1. Foundations of Prescribing Practice. Make notes on the essential requirements for a valid PGD form and the essential requirements for a valid CMP.

Make comparisons of the differences between the two.

Reflection

Consider your own patient group.

Some of your patients may benefit from prescribing within a PGD, but others may benefit from supplementary prescribing under a CMP.

It may be useful to discuss this with your supervisor.

Further Reading

Further reading

Baird, A. (2003) How to write a clinical management plan. Nurse Prescriber. 1 (2) 93-94.

Belton, J. (2005) Developing a computer based clinical management plan for supplementary prescribing. Nurse Prescribing. 3 (2) 76-78.

Hennell, S., Wood, B., Spark, E. (2004) Competency and the use of clinical management plans in rheumatology practice. Nurse Prescribing 2: 1, 26-30.

Madden, V. (1995) The role of management plans in asthma control. Prescriber 6: September 19, 42-43.

Electronic patient records and electronic prescribing

Reading

NMC Guidelines for Records and Record Keeping (2005)
http://www.nmc-uk.org/(vo2j3jmaqtz4kuyl2zxifkeh)/
aFrameDisplay.aspx?DocumentID=516

References to computer held records are on pages 13-14.

NMC Standards of Proficiency for Nurse and Midwife Prescribers (2006) lay out further guidance in Practice Standard 12.
http://www.nmc-uk.org/aArticle.aspx?ArticleID=2021

The concept of an electronic health record is to provide a longitudinal record of a patient's health and healthcare to combine information from primary healthcare with periodic care from other institutions.

Computer-held records have many advantages:

  • They are less bulky than paper records
  • They reduce need for duplication
  • They are more legible than written records
  • They allow for increased communication across the interprofessional healthcare team
  • They can have different access levels, to ensure that sensitive data is hidden from anyone who does not need to know it
  • They are searchable, which simplifies and speeds up the audit process
  • They can record the time and the date of all entries, leaving a clear audit trail of changes.

However, they also have disadvantages, in that they need:

  • Access to computer equipment
  • Some specialist training
  • Protection from unauthorised access and virus attack
  • IT expertise to maintain and to back up the system.

The same basic principles that apply to manual records must be applied to computer-held records. You are accountable for any entry you make — it is attributed to you electronically when you log on to the system. You must therefore always make sure that you log on and off correctly, to prevent anyone else making entries in your name.

The computer can make it harder to maintain a dialogue with the patient during a consultation. It is therefore important to ensure that the monitor is positioned in such a way as to enable you to look at the patient during a consultation. Consideration must also be given to confidentiality, as it is possible for those accompanying the patient to see past records on screen or for one patient to see the record of the next patient if this is opened too soon. Screen savers set on a short timer and well-designed desk areas can avoid such problems.

The use of electronic prescribing has the potential to benefit the healthcare system, as it has advantages for patients, prescribers and pharmacists.

One in 20 hospital admissions is for treatment of side-effects related to drugs or the results of drug interactions (Einarson, 1993). Errors can be reduced in electronic prescribing because the system checks for drug interactions and issues a warning if there is a contraindication. Medication is normally chosen from a menu, which can default to a selected local formulary. The system will ensure that all the details — such as dosage and route — are completed. However, caution should be exercised when choosing medication from among similarly named drugs or medication with multiple dosages because a incautious mouse click can result in a prescription error.

Electronic transmission of prescription (ETP) is now possible where the computer technology is available. It enables an encrypted prescription to be sent to a nominated community pharmacy. ETP has advantages for many patients, for example for those who are housebound, and is seen as an important step in the battle against prescription fraud.

Link to another Unit

You will find more information on awareness and reporting of fraud in the 'Prescription writing' section of Unit 5. Prescribing Partnerships.

PRODIGY (Prescribing Rationally with Decision Support In General Practice Study) is a computerised decision-support system that has been on trial in general practice in the UK since 1996. It can be used on some general practice computer systems during a consultation and is also available at:
www.prodigy.nhs.uk

A diagnosis is entered into the system and PRODIGY offers decision support by presenting clinical advice and prescribing recommendations, along with non-drug treatments and patient-information leaflets. The PRODIGY web site has information on many aspects of nurse prescribing and has guidance on conditions that can be managed by independent nurse prescribers.

Make Notes

Write down what you consider to be the advantages and disadvantages of electronic patient records and electronic prescribing.

Further Reading

Further reading

Middleton, H. (2000) Electronically transmitted prescriptions — a good idea? Pharmaceutical Journal 265: 7107, 172-176.
www.pharmj.com/Editorial/20000729/
articles/electronicprescriptions.html

Purves, I.N. (1998) PRODIGY: implementing clinical guidance using computers. British Journal of General Practice 48: 434, 1552-1553.

Reporting adverse drug reactions via the Yellow Card scheme

Refer Back

Link to 'Adverse reactions and Yellow Card reporting to the Committee on Safety of Medicines' in the 'Absorption, distribution, metabolism and excretion' section of Unit 2. Clinical Pharmacology, including the Effects of Co-morbidity.

The people who can report using the Yellow Card scheme are:

  • Doctors
  • Pharmacists
  • Dentists
  • Coroners
  • Nurses
  • Midwives
  • Health visitors.

The scheme provides two methods of reporting incidents:

  1. A paper-based version of the Yellow Card is included as part of the print editions of the
    BNF.

  2. You can access the electronic Yellow Card by logging on to the following web site:
    www.yellowcard.gov.uk
Reflection

Look at the Yellow Card at the back of the NPF/BNF. Could you confidently complete it? If not, revisit the areas you are unsure of.


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