prescribing skills assessment – prescribing question item authoring tool prescribing skills...

Prescribing Skills Assessment – Prescribing Question Item Authoring Tool

Prescribing Skills Assessment

Prescribing Question Item Authoring Tool

This file contains a guide to authoring question items as well as example

question items

Please turn to the next page

Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

http://www.chms.ac.uk/default.html


Information Given to Candidates• This is a Prescribing Skills Assessment created by the Medical Schools Council and British Pharmacological

Society with the aim of assessing knowledge, skills and judgement related to prescribing medicines.

• This assessment is designed for medical students who are in the final months of their undergraduate studies and are due to graduate shortly.

• We are asking you to identify yourself on the next page so that we can look for correlations between results of this test and the local assessment process.

• There will be 12 stations testing various aspects of prescribing, reviewing and advising about medicines as a Foundation doctor, mapped against the learning outcomes identified by the General Medical Council in Tomorrow’s Doctors (2009).

• You will have 1 hour to complete the whole assessment.

• The weighting of each station is summarised on the next page and the marks allocated to individual question items within it will be clearly marked.

• This assessment will not carry negative marks.

• The invigilator will indicate the time when 15, 30, and 45 minutes have passed.

• You are allowed the use of a BNF and a calculator at any time.

• Commonly used abbreviations are provided on the page after next.

Candidates should be allowed 5 minutes to go through this information

This page shows you the information provided to the candidates prior to the start of the pilot assessments.



Station Description Marks Comments

1 Prescribing 1 10 1 question item of 10 marks


3 Prescription Review 1 8 2 question items of 4 marks each

4 Planning Management 8 2 question items of 4 marks each

5 Communicating Information 6 3 question items of 2 marks each

6 Drug Calculation Skills 8 4 question items of 2 marks each



9 Prescription Review 2 8 2 question items of 4 marks each

10 Adverse Drug Reactions 8 4 question items of 2 marks each

11 Drug Monitoring 8 4 question items of 2 marks each

12 Data Interpretation 6 3 question items of 2 marks each

TOTAL MARKS 100This page shows you the overall

structure of the one hour assessment with the weighting

of the individual stations.

This document has been written to help you create

question items for the Prescribing Stations.

Prescribing Skills Assessment – Format



AbbreviationsPrescribing abbreviationsdaily once each day (usually

in the morning)nightly once each day at

bedtime12-hrly twice each day

(morning and evening)8-hrly three times each day

6-hrly four times each day4-hrly six times each day

as required as often as necessary

IM intramuscularIV intravenousORAL by mouthSL sublingualSC subcutaneous

Examination findingsBP blood pressure (mmHg)HR heart rate (per minute)HS heart soundsJVP jugular venous pressure

(centimetres)RR respiratory rate (per

minute)O2 sat arterial oxygen

saturation (%)

InvestigationsHb haemoglobinWCC white cell countPT prothrombin timeaPTT activated partial thromboplastin time

Na+ serum sodiumK+ serum potassiumU serum urea Cr serum creatinineeGFR estimated glomerular filtration rateBili serum total bilirubinALT serum alanine aminotransferaseAlk phos serum alkaline

phosphatase

ECG electrocardiogramCXR chest X-rayAXR abdominal X-rayUS ultrasound scan

Unitsmmol/L millimoles per litreµmol/L micromoles per litreg/L grams per litre

OthersPMH past medical historyDH drug historyFH family historySH social historyBNF British National FormularyGP general practitionerKCl potassium chlorideCOPD chronic obstructive pulmonary disease

This page is provided to the candidates before the assessment and highlights

acceptable abbreviations that you may use when authoring questions



PRESCRIBING• Reasoning and judgement: Deciding on the most appropriate prescription (drug, dose, route and

frequency) to write, based on the clinical circumstances and supplementary information. • Measurable action: Writing a safe, effective and legal prescription for a single medicine, using the

documentation provided to tackle a specific indication highlighted by the question.• This question type will present a clinical scenario followed by a request to prescribe a single appropriate

medicine or fluid. It will be distinguished from other station types by the specific requirement to write a prescription on one of a variety of prescription charts. Typical scenarios will involve the treatment of acute conditions (e.g. acute asthma attack, acute heart failure), chronic conditions (e.g. depression, reflux oesophagitis) and important symptoms such as pain. The candidate will have to exercise judgement when deciding between different drugs, different formulations, different routes, different doses, and different dose intervals. Typical medicines that will be prescribed will include those that are high-risk (e.g. anticoagulants, opioids, insulin), those that are in common use (e.g. antibiotics), and intravenous fluids. It is expected that prescriptions will meet appropriate standards: they must be legible, unambiguous and complete (approved name written in upper case, appropriate form and route, correct dose appropriately written without abbreviations, necessary details and instructions, signed).

• The purpose will be to demonstrate the ability to write a safe and effective prescription [TD 17(c)][SPWG 3], to manage acute medical emergencies [TD 16(b)], and to plan appropriate drug therapy for common indications [TD 8(e) and 17(b)][SPWG 2].

TD = Tomorrow’s Doctors (General Medical Council, 2009) SPWG = Safe Prescribing Working Group (Medical Schools Council, 2008)

This page contains information about the nature and purpose of Prescribing Station question items as described in the assessment blueprint document



The following pages are templates for creating Prescribing Station question items.

Good Prescribing question items should:• be based on a clinical scenario that might be faced by and actions that might

reasonably be expected of a Foundation doctor• avoid using over-elaborate clinical scenarios containing excessive amounts of

information • state clearly the symptom or problem to be addressed by the prescription

within the ‘Prescribing Request’ box • require only one prescription to be written.

You have the option to create items that involve prescriptions written into a variety of prescription forms, including hospital once-only, regular medicines, fluid prescription charts and general practice (FP10) forms.

It is rarely possible to create clinical scenarios that have only one correct answer. We would like you to identify those answers that you believe to be optimal and those that are suboptimal but worthy of credit. This can be done on the Answer page that follows the question template.



Please use the British National Formulary, to which the candidates will have access

throughout, as the ultimate arbiter of dose ranges, routes, indications, contra-

indications, etc.



Prescribing Item

Case presentationA [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] [Authors should try to adhere to this general layout but there is room for flexibility] On examinationTemperature xx°C, HR xx/min and regular, BP xxx/xx mmHg, JVP xxxxxx, RR xx/min, O2 sat xx% on air, HS xxxxxx, chest sounds xxxxxxx. Other important observations are …….

InvestigationsNa+ xxx mmol/L (137–144), K+ xxx mmol/L (3.5–4.9), U xxx mmol/L (2.5–7.0), Cr xxx µmol/L (60–110), eGFR etc.ECG shows ………CXR shows ………

[Authors should provide sufficient information from the clinical examination and investigations to enable the candidate to make a sound judgement about the need for and choice of treatment]

Prescribing requestWrite a prescription for ONE drug that will help to [treat/alleviate/prevent] [symptom or problem].(use the hospital ‘once-only medicines’ prescription chart provided)

Please paste any picture or other illustration that supports the clinical case into this box

PWS000ID This question item is worth 10 marks You may use the BNF at any time

ONCE ONLY MEDICINES

DateTim

e Medicine (Approved name) Dose Route Prescriber – sign + printTim

egiven

Given

by



Marking guide for A and B. Candidates should be given 4 marks for an optimal answer that can’t be improved. They should get 3 marks for an answer that is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit.

PWS000ID This question item is worth 10 marks You may use the BNF at any time Answer Page

C. Timing. Candidates will also be given 1 mark for correctly dating (and timing) the prescription

D. Signature. Candidates will also be given 1 mark for signing the prescription

A. Drug choice Score Feedback/justification B. Dose and route Score Feedback/justification

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Prescribing Item

It is impossible to write Prescribing items with only one creditworthy answer! Use this page

to indicate optimal answers (10/10) but also to anticipate and score as many suboptimal answers using the scoring system below.



To create further question items simply copy and paste the blank

templates and answer pages

The following pages contain templates for creating Prescribing Station question items that use other prescription charts and forms, such as regular medicines, fluid prescription charts and

general practice (FP10) forms






Prescribing requestWrite a prescription for ONE drug that will help to [treat/alleviate/prevent] [symptom or problem].(use the hospital ‘regular medicines’ prescription chart provided)


PWS000ID This question item is worth 10 marks

Date

Time

Drug (Approved name)

68Dose Route

12Prescriber – sign + print Start date 14

18Notes Pharmacy

22

You may use the BNF at any time Prescribing Item







A. Drug choice Score Feedback/justification B. Dose, route, freq. Score Feedback/justification

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Prescribing Item








Prescribing requestWrite a prescription for ONE drug that will help to [treat/alleviate/prevent] [symptom or problem].(use the general practice prescription form provided)



Pharmacy Stamp

Please don’t stamp over age box

Age0yr 0mths

D.o.B.00/00/0000

Title, Forename, Surname & AddressPatient NameAddress Line 1Address Line 2Town Postcode

Number of days’ treatmentN.B. Ensure dose is stated

Endorsements Drug nameDoseFrequency

Signature of PrescriberSignature

Date00/00/0000

ForDispenserNo. ofPrescns.on form

Xxxxx Health AuthorityDr AddressTown PostcodeTel: 00000 000 000

FP10NC0105








A. Drug choice Score Feedback/justification B. Dose, route, freq. Score Feedback/justification

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Prescribing Item







Prescribing requestWrite a prescription for ONE intravenous fluid that would be most appropriate for the patient at this point.(use the hospital fluid prescription chart provided)



INFUSION THERAPY

Date Start time

Infusion solution Medicine added Prescriber’s signature

Given by

Type/strength Volume Route Rate Duration Approved name Dose








A. Fluid choice Score Feedback/justification B. Volume and duration Score Feedback/justification

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Prescribing Item





The following pages contain examples of Prescribing Station question items written

using the previous templates



Case presentationA 74-year-old man presents to the medical assessment unit complaining of shortness of breath at rest and swollen legs. These symptoms have been gradually increasing over the last 2 weeks. He has been having difficulty sleeping and sat up in a chair all of last night, calling his doctor this morning. PMH. He has ischaemic heart disease and hypertension, both of which are normally well controlled. DH. He normally takes ramipril 10 mg orally daily, isosorbide mononitrate 60 mg orally daily, simvastatin 40 mg orally nightly, and aspirin 75 mg orally daily. An intravenous infusion of glyceryl trinitrate has just been started.

On examinationHR 105/min and regular, BP 110/70 mmHg, JVP elevated at 6 cm, RR 30/min, O2 sat 93% on air. HS third heart sound. Examination of the chest reveals dullness to percussion both bases and fine inspiratory crackles in both lower and mid zones. Bilateral swollen legs with pitting oedema to knees.

InvestigationsNa+ 141 mmol/L (137–144), K+ 4.2 mmol/L (3.5–4.9), U 7.0 mmol/L (2.5–7.0), Cr 120 µmol/L (60–110). ECG shows sinus tachycardia. The CXR is illustrated (right).

Prescribing requestWrite a prescription for ONE drug that will help to relieve his fluid overload and breathlessness. (use the hospital ‘once-only medicines’ prescription chart provided)


ONCE ONLY MEDICINES

DateTim


egiven

Given

by


Prescribing Item









1 Furosemide 4 This is a powerful loop diuretic and is one of the drugs most likely to achieve a significant diuresis.

40–100 mg IV 4 This dose and route would be likely to achieve a significant diuresis (doses > 50 mg should be given by slow IV infusion)

2 <40 mg IV 2 This dose may produce a suboptimal diuresis

3 >100 mg IV 2 This is an unnecessarily high dose of furosemide that risks causing adverse effects in a diuretic naïve patient

4 20 mg oral 1 This dose is unlikely to be effective

5 40–100 mg oral 2 Any oral route will be less effective than IV

6 >100 mg oral 1 This dose is excessive and the route would be less likely to achieve a significant diuresis

7 Bumetanide 4 1–2 mg IV 4 This dose and route would be likely to achieve a significant diuresis

8 <1 mg IV 2 This dose runs a significant danger of producing a suboptimal diuresis

9 >2 mg IV 2 This is an unnecessarily high dose of bumetanide that risks causing adverse effects in a diuretic naïve patient

10

1-2 mg oral 2 Any oral route will be less effective than IV

11

oral dose outside this range 1 This dose and route are inappropriate

12

Torasemide 2 This is a powerful loop diuretic but is available only via the oral route

5 – 40 mg oral 2 This is the correct dose of torasemide but a parenteral loop diuretic should have been chosen

13

Any thiazide diuretic 1 This is a thiazide diuretic, which will not have sufficient efficacy to achieve a significant diuresis

Correct dose and route 1 This is the correct dose but a parenteral loop diuretic should have been chosen

14

Any other diuretic 0 This kind of diuretic will not have sufficient efficacy to achieve a significant diuresis

15

Nitrates 0 The patient is already being given a nitrate

16

Morphine/diamorphine 2 May redistribute fluid but will not improve fluid overload 2.5–10 mg/2.5–5 mg 2 Higher doses would be hazardous (0 marks)

Prescribing Item



Case presentationA 60-year-old man is admitted to the acute medical admission unit with a 2-month history of intermittent epigastric pain radiating to the back, which typically occurs 2 or 3 hours after meals and at night. His weight has remained stable and he has not been vomiting. He has recently been suffering from pain in his left knee. PMH. None. DH. No regular medicines but he has been taking ‘over-the-counter’ pain killers on a daily basis. SH. He is a non-smoker and drinks alcohol in moderation (10 units/week). On examinationHe appears well but has some epigastric tenderness on abdominal examination.

InvestigationsHb and MCV normal. Serum biochemistry normal. Endoscopy reveals a small duodenal ulcer but no evidence of bleeding. Tests for H pylori infection are all negative.

Prescribing requestWrite a prescription for ONE drug that will promote the healing of the duodenal ulcer.(use the hospital ‘regular medicines’ prescription chart provided)


Date

Time

Drug (Approved name)

68Dose Route

12Prescriber – sign + print Start date 14

18Notes Pharmacy

22








A. Drug choice Score Feedback/justification B. Dose, route, frequency Score Feedback/justification

1 Omeprazole 4 A proton pump inhibitor is the optimal choice for the treatment of a benign duodenal ulcer

20 mg oral once daily 4 This is the optimal dosage and should be given for 4 weeks in the first instance

2 10 mg or 40 mg oral once daily 3 This dosage is too low/too high.

3 Lansoprazole 4 A proton pump inhibitor is the optimal choice for the treatment of a benign duodenal ulcer

30 mg daily oral once daily 4 This is the optimal dosage and should be given for 4 weeks in the first instance

4 15 mg oral once daily 3 This dosage is too low.

5 Esomeprazole 3 A proton pump inhibitor is the optimal choice but esomeprazole is much more expensive than others and is not indicated for benign duodenal ulcer

10 or 20 mg oral once daily 3 This is the correct dosage

6 Pantoprazole 4 A proton pump inhibitor is the optimal choice for the treatment of a benign duodenal ulcer

40–80 mg oral once daily 4 This is the optimal dosage and should be given for 2 weeks in the first instance

7 Rabeprazole sodium 3 A proton pump inhibitor is the optimal choice but rabeprazole is much more expensive than others

20 mg oral once daily 3 This is the optimal dosage and should be given for 4 weeks in the first instance

8 Any of the above by the intravenous route in the correct dose

2 The intravenous route is unnecessary in this clinical situation

9 Ranitidine, cimetidine, famotidine, nizatidine

3 An H2-antagonist is a good choice for the treatment of a benign duodenal ulcer but is less effective than a proton pump inhibitor

300 mg oral at night or 150 mg oral twice daily 3 This is the optimal dosage and should be given for 4 weeks in the first instance

10 An inappropriate but prescribable dose 2 This is not the optimal dosage of this drug for the indication

11 Misoprostol 1 A prostaglandin analogue that can be used to treat and prevent duodenal ulcers but is less effective and more expensive than other drugs

400 micrograms oral twice daily200 micrograms oral four times daily

1 This is the optimal dosage and should be given for 4 weeks in the first instance

12 Antacid preparations 1 Antacids are effective for relieving symptoms but not for healing duodenal ulcers at conventional doses.

Appropriate high antacid dose 1

13 DeNol/Sucralfate 1 These preparations are indicated for treating duodenal ulcers but are rarely used and unlikely to be immediately available from a hospital pharmacy

Appropriate doses 1

Prescribing Item



Case presentationA 68-year-old woman is reviewed in a primary care cardiovascular clinic with hypercholesterolaemia. After a careful explanation she is keen to have drug treatment to lower her cholesterol. PMH. Hypertension. DH. Bendroflumethiazide 2.5 mg orally daily, lisinopril 20 mg orally daily, amlodipine 5 mg orally daily. FH. Nil relevant. SH. She eats a sensible diet and is a non-smoker.

On examinationShe has an early corneal arcus in both eyes. BP 130/70 mmHg.

InvestigationsNormal FBC, renal, liver and thyroid function tests. Normal fasting plasma glucose and HbA1c. Serum cholesterol 7.5 mmol/L (<5.2), LDL cholesterol 5.50 mmol/L (<3.36), HDL cholesterol 1.20 mmol/L (>1.55), fasting serum triglycerides 1.90 mmol/L (0.45–1.69). Normal ECG.

Her 10-year cardiovascular risk is estimated to be 23%.

Prescribing requestWrite a prescription for ONE drug that will reduce her serum cholesterol and risk of cardiovascular events.(use the general practice prescription form provided)


Pharmacy Stamp

Please don’t stamp over age box

Age0yr 0mths

D.o.B.00/00/0000

Title, Forename, Surname & AddressPatient NameAddress Line 1Address Line 2Town Postcode

Number of days’ treatmentN.B. Ensure dose is stated

Endorsements Drug NameDoseFrequency

Signature of PrescriberSignature

Date00/00/0000

ForDispenserNo. ofPrescns.on form

Xxxxx Health AuthorityDr AddressTown PostcodeTel: 00000 000 000

FP10NC0105








A. Drug choice Score Feedback/justification B. Dose, route, frequency Score Feedback/justification

1 Simvastatin 4 A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk

20 mg or 40 mg oral once daily(10 mg too low, 80 mg too high = 2 marks)

4 This is an appropriate starting dosage and is normally prescribed nightly.

2 Atorvastatin 3 A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk but atorvastatin, although more efficacious, is less cost-effective

10 mg oral once daily20 – 80 mg oral once daily

32

This is an appropriate starting dosageThis starting dosage is unnecessarily high

3 Rosuvastatin 3 A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk but rosuvastatin, although more efficacious, is less cost-effective

5–10 mg oral once daily20 – 80mg oral once daily

32


4 Pravastatin sodium 2 A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk but pravastatin is less efficacious and more expensive

10–40 mg oral once daily 2 This is an appropriate starting dosage

5 Fluvastatin 2 A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk but fluvastatin is less efficacious and more expensive

20–40 mg oral once daily80 mg oral once daily

21


6 Simvastatin with ezetimibe

2 A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk but use of a combination product is not indicated

40 mg/10 mg oral once daily 2 This is an appropriate starting dosage

7 Ezetimibe 1 A cholesterol absorption inhibitor that is much less efficacious and more expensive than simvastatin

10 mg oral once daily 1 This is an appropriate starting dosage

8 Fibric acid derivatives 2 Fibric acid derivatives are less efficacious and more expensive than simvastatin

Appropriate dose 2 This is an appropriate starting dosage

9 Bile acid sequestrants 2 A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk and sequestrants are less efficacious and more expensive


10

Nicotinic acid derivatives 1 A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk and nicotinic acid derivatives are less efficacious and more expensive


11

Omega-3 fatty acids 1 These lower cholesterol but are not indicated Appropriate dose 1 This is an appropriate starting dosage

Prescribing Item



Prescribing Item

Case presentationA 62-year-old woman is admitted to hospital with a 3-day history of increasing breathlessness, wheeze, and dry cough. PMH. Chronic obstructive pulmonary disease with several admissions for exacerbations, and angina pectoris. DH. Salbutamol inhaler 200 micrograms as required, tiotropium inhaler 18 micrograms daily, fluticasone propionate 250 micrograms with salmeterol 50 micrograms inhaler (Seretide 250 Accuhaler®) 12-hrly. Treatment with oral prednisolone has already been started by the GP.

On examinationShe appears distressed, and is centrally cyanosed and coughing.Temperature 37.1°C, HR 112/min, BP 116/72 mmHg, RR 30/min, O2 sat 90% on air. PEFR 120 L/min. She is using her accessory muscles to breathe. Auscultation of the chest reveals widespread wheezes bilaterally.

InvestigationsHb 146 g/L (115–165), WCC 9.8 × 109/L (4.0–11.0).Na+ 140 mmol/L (137–144), K+ 4.2 mmol/L (3.5–4.9), U 7.2 mmol/L (2.5–7.0), Cr 85 µmol/L (60-110). CXR shows hyperexpanded lungs.

Prescribing requestPlease write a prescription for ONE drug that will provide rapid relief of her bronchospasm. (use the hospital ‘once-only medicines’ prescription chart provided)


ONCE ONLY MEDICINES

DateTim


egiven

Given

by








1 Salbutamol 4 Commonest drug for this situation 2.5 – 5 mg nebulised 4 Probably the most effective route

2 100– 200 micrograms inhaled 2 Already on it/less easy to administer/less effective

3 Dosages outside these ranges 2 Dosages would be hazardous

4 Other routes with right dosage 0 Other routes more hazardous or less effective

5 Terbutaline 4 Equivalent to salbutamol in efficacy 5 – 10 mg nebulised 4 Probably the most effective route

6 500 micrograms inhaled 2 May be less easy to administer/less effective

7 Dosages outside these ranges 2 Dosages would be hazardous

8 Other routes with right dosage 0 Other routes more hazardous or less effective

9 Ipratropium bromide 3 Anticholinergic drug equally effective in COPD but the patient is already on tiotropium

250– 500 micrograms 3 This is the correct dose range for the nebuliser

10

Dosage outside this range 1 Hazardous or ineffective

11

20 – 40 microgram inhaled 1 Already taking an inhaled anticholinergic drug

12

Duovent 4 Compound preparation via nebuliser that has equivalent efficacy to either alone.

Correct nebulised dose 4 The most effective route of administration

13

Combivent 4 Compound preparation via nebuliser that has equivalent efficacy to either alone.

Correct nebulised dose 4 The most effective route of administration

14

Oral theophyllines 1 Effect too delayed to be useful Correct oral dosage 1

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Aminophylline 2 This would pose greater than necessary hazards as a firstline treatment

An appropriate intravenous loading dosage (250–500 mg)

2 This dose implies a body weight of 50–100 kg although weight not given (other doses get zero)

16

Tiotropium 0 The patient is already taking tiotropium

17

Adrenaline 0 Would be unacceptably hazardous in this situation

18

Salmeterol, indacaterol, formoterol, bambuterol

0 Patient is already taking a long-acting beta-2 agonist

Prescribing Item


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