repeat prescribing procedure€¦ · 1. requests for repeat medicines requests should be sent to...

GP Practice Repeat Prescribing Guidance of 14 May 2015 Medicines Management Team

Introduction

This guidance is intended for use by practice staff involved in the repeat prescribing process. All practices should have a written repeat prescribing policy which is adapted to meet their local needs. This guidance sets out the procedures to be followed to ensure good practice in the management of practice based repeat prescribing, to ensure the maintenance of a secure, user-friendly, cost effective and efficient system. The guidance should be used in conjunction with related prescribing procedures and guidance. The guidance will be revised alongside developments in repeat dispensing and electronic transmission of prescriptions. Repeat prescribing accounts for around 75% of prescriptions issued in general practice, with approximately half of all patients receiving repeat prescriptions. Repeat prescribing (RP) is a complex journey involving over 20 steps from the initial decision to prescribe to the patient finally taking the medication. Patients, staff, GPs and pharmacists all have a role to play in minimising error. RP is everyone’s responsibility. Ultimately however the clinician who signs the prescription is legally responsible for it. There are many risks, bottlenecks and potential for omissions and duplications along this complex journey often involving several people, and it is important to identify these and ensure the system is safe and robust.

GP Practice Repeat Prescribing Guidance

Content

1. Requests for Repeat Medicines 2. Issuing a Repeat Prescription 3. Managing Repeat Prescriptions Repeat Status Length of Supply Reauthorisation of Repeat Prescriptions Frequency of Issues 4. Printing and Collection of Repeat Prescriptions 5. Ensuring Repeat Prescriptions are up to date 6. When to Refer Request for Repeat Prescription to Prescriber 7. Adding Hospital Discharge / Outpatient Appointment Medication to Repeat 8. Medication Reviews 9. Controlled Drugs 10. Implementation and Review References 1. Requests for Repeat Medicines Requests should be sent to the practice a maximum of 7 days in advance of supply except in

exceptional circumstances e.g. patient going on holiday. An explanation of the early supply should be documented in the patients’ record. Repeat templates should be set up with a minimum number of days allowed between prescription issues. The following personnel are allowed to request repeat prescriptions:

Patient Carer District nurse (by prior arrangement) Pharmacist (nominated pharmacist by prior arrangement) Care home staff (by prior arrangement) Appliance contractor (by prior arrangement)


Where there is a third party request staff must:

Assure patient confidentiality Ensure the correct information is accurately exchanged, when those making the request

are not fully aware of the medications Guarantee probity

Requests can be received from patients in a number of ways; it is good practice to record the method of request at the point of issue:

Repeat Request Slip (issued with prescription)

This is the most popular method as it is the most accurate. A collection point should be established in the practice. A secure box will ensure that the information contained on the prescription is not available to other patients.

Via the pharmacy Most pharmacies now offer a repeat prescription request service. This is designed to save the patient having to visit the surgery to collect scripts. This works well only if robust repeat prescribing systems are in place at the surgery. Also pharmacies operating the service should keep robust records as required by professional ethics guidelines. Patients sign a consent form to allow the pharmacy to request a repeat prescription from the GP on their behalf. The pharmacy must contact the patient or their carer to establish which medicines are required to ensure that unnecessary supplies are not made, it is good practice that the pharmacy stamp and date the repeat slip to confirm that contact has been made (this contact must be made within 7 days of when the prescription is due). Requests should be sent to the practice a maximum of 7 days in advance of supply except in exceptional

circumstances. The practice should assure themselves that this process is being followed and that requests are being authorised by the patient or carer. If Practices have concerns about the repeat prescription service provided by the pharmacy they should discuss the issues directly with the pharmacy concerned before escalating their issues to the Primary Care Prescribing Team.

Note that if a repeat prescription is cancelled in practice, any previously printed repeat slips may still contain the cancelled medicine. Requests made for items that have been removed from repeat must not be issued unless authorised by and added back onto repeat by a prescriber.

Online requests Patients may choose the option of being able to order their repeat prescriptions on line. If so, this must be a secure process, with password protection for each individual patient.

Telephone or verbal request

Telephone requests are convenient for the patient but have a greater potential for errors. This is only recommended when the following parameters are met due to safety concerns:

Separate phone line for repeat prescription requests, or requests should be restricted to certain hour(s) during the day.

The telephone should be next to a computer screen for on screen confirmation of the request.

Telephone and computer should be in a separate area, avoiding the noise and distractions of the reception area.

Trained staff with telephone skills Trained receptionist(s) managing all repeat prescriptions.

The following details should be obtained from the patient and if necessary documented carefully and accurately:


a. The Name, Date of Birth and Address of the patient b. The details of the item requested i.e. drug name, dose and quantity (please check

with the patient that they have only ordered items that they require to reduce wastage)

c. Collection time and place e.g. pharmacy or practice

All details should be confirmed with the patient to avoid errors.

Faxing requests

The practice can also set up systems to receive requests by fax; this would be possible for a minority of requests and normally under exceptional circumstances.

2. Issuing a Repeat Prescription The practice computer system must be used for generation of all repeat prescriptions to ensure a clear record of supplies. It is good practice to have a list of medications which are not permitted in the repeat system clearly visible at the point of generating the repeat prescription e.g. benzodiazepines, antibiotics, sip feeds. Staff members should confirm the patients’ details to ensure they access the correct patient’s computer record

The item may be issued if it complies with the following rules:

The item requested has repeat status

The dosage of the item is the same as on the repeat screen

The item has current authorisations available

The item is not being ordered early (unless there is a valid reason) The item has been ordered in the last six months

The patient’s medication review is not overdue (if a review is required, the patient should be advised to make this appointment)

The item is not a controlled drug

All requests that do not fulfil the rules outlined above or requests where there is any doubt as to whether a repeat prescription is appropriate must be referred to the prescriber. An audit trail should be maintained to ensure these items are followed up. Standard communication notes can be useful so that the message is easily identifiable to the prescriber. Although the member of staff printing the repeat prescription is responsible for making sure these checks are made before printing, ultimate responsibility for the prescription itself lies with the prescriber that signs it. 3. Managing Repeat Prescriptions Repeat Status

Generally, new medication is added to the patients’ computer records as an acute item and reviewed after 1-2 months. Most prescription items will be suitable for repeat status. The prescriber may wish to consider an initial prescription for 2 weeks in case the medicine doesn’t suit the patient. Please ensure that if a new medication is added that any interactions are identified and reviewed as appropriate. Each time a repeat prescription is issued, the prescriber must check the repeat item is still needed, effective and tolerated, the necessary monitoring requirements are fulfilled and the patient’s condition is still stable enough to warrant a repeat prescription without further examination or assessment.


There are certain medicines, which are not routinely appropriate for repeat status. These include: antibiotics, hypnotics and anxiolytics, potent topical corticosteroids, controlled drugs and dressings. Each practice must agree which members of staff may generate repeat prescriptions and these staff must be appropriately trained. New items should only be added by prescribers. The prescriber has overall responsibility for all prescriptions, either acute or repeat.

Length of supply The majority of prescriptions should be for 28 days. The prescriber can use their discretion to allow 56 days’ supply if deemed appropriate, this might include patients who are on stable long

term medication. (Exceptions to this policy include HRT and oral contraceptives which may be prescribed for up to 3-6months). Prescribers should ensure that the issue duration is correct and that all items are standardised to the same supply duration. Longer supply lengths are not recommended, as there is an increased potential for waste when medication or the patient’s condition changes. Prescriptions for durations of seven days should only be issued to patients where there is a clinical need for them to only receive seven days medication at any one time. This is also applicable to those patients who have medicines dispensed in a compliance aid (dosette box), where it is inappropriate for the patient to receive more than one compliance aid at a time for clinical reasons. If seven day prescriptions are considered appropriate, ensure that items not supplied in the compliance aid, such as inhalers, are only issued as often as needed and not on a weekly basis. For most patients with a compliance aid (dosette box) 28 day prescriptions are appropriate. Reauthorisation of prescriptions

Most items should be re-authorised every 6-12 months. This allows the prescriber to review the treatment and call the patient for a medication review as appropriate. The use of a review date for reauthorisation is preferred to number of issues. This allows one review date for all items and avoids different medicines having to be issued at different times. Frequency of Issues Regular items should generally be requested every 28 or 56 days depending on prescription supply length. Requests should be sent to the practice a maximum of 7 days in advance of

supply except in exceptional circumstances. Items that have not been requested within last 6 months should be referred to the prescriber. Exceptions include items that are clearly intended for ‘when required’ use e.g. GTN spray and medicines that are used for seasonal conditions, such as hay fever. The practice may find it useful to have an agreed list of seasonal medication for reception staff to refer to. All items on a repeat prescribing template should be linked to an indication/read code. 4. Printing and Collection of Repeat Prescriptions

After issuing the item, the prescription should be printed (or electronically created) and the details of the request confirmed again. The prescription should be left for signing in the area agreed by the practice (unless electronic). Ideally the patient’s usual prescriber should sign the prescription with reference to the patient’s notes.


In order to maintain an efficient repeat prescribing process, it is desirable to feed the prescriptions through for signing on a continual basis. This will avoid large batches of prescriptions being signed together.

Paper prescriptions should be safely stored in a designated area within the practice reception so that they are easily accessible by authorised personnel only and cannot be accessed by patients, carers or the pharmacy staff. Care should also be taken that the prescriptions cannot be read by unauthorised personnel. When the patient collects the prescription, a final check of the details should be carried out to confirm patient identification. The practice should monitor the process and make any reasonable adjustment necessary to the collection process to ensure that the prescription is not supplied to the wrong patient. A similar system should be in place for pharmacy collections to ensure that prescriptions are collected by an authorised member of staff. It is considered good practice to keep a record of prescriptions collected by pharmacy staff especially prescriptions picked up by their collection/delivery drivers. The practice may decide to have a separate process for the collection of controlled drug (CD) prescriptions. This can avoid patient disputes over whether or not the prescription was collected. It is recommended that all pharmacy collection/delivery drivers sign for CD prescriptions.

Patients requiring repeat prescriptions should be able to access them within a specified period of time, usually less than 48 or 72 hours. The practice should have a clearly defined ordering system for repeats which suits both the practice and the patient needs, and which is communicated to patients and staff. The practice staff should emphasise to the patient that the need for 48 or 72 hours is to ensure the safe prescribing of repeat medication. There should be a separate system for dealing with ‘urgent’ prescriptions. The use of patient reminder notices can be useful to highlight the need for the patient to attend the surgery for a review before their next prescription is due. This can also be communicated on the prescription itself. Each practice should also have a system for dealing with care home prescription requests. If a repeat prescription is requested but not collected within 28 days, this should be cancelled on

the GP system and a note should be made in the patient record that it was not collected. 5. Ensuring Repeat Prescriptions Are Up To Date

The efficiency of a repeat prescribing system is maintained by making sure that computer information is up to date and accurate. The following housekeeping checks should be carried out on a regular basis and referred to the prescriber to address as appropriate:

Check all prescriptions have specific and accurate dosage instructions, (as directed, one as directed - are not adequate instructions). If an item is “To be used as

required”, ensure there is a maximum daily dose stated. Check all items have been requested in the last six months, except for agreed

exceptions. (This identifies compliance issues and opportunities to discontinue items no longer required.)

Check for opportunities to discontinue duplicated items on the patient’s record.

Check that a reason is documented for discontinued items e.g. duplication/side-effects etc.

Check all items for each patient have the same length of supply e.g. 28 or 56 days. Check all items have an appropriate issue duration e.g. 28 or 56


Check for opportunities for re-alignment of medication quantities. (This assists patients being able to order all regular items together.)

Check all new items are added to the patient’s record.

Check all handwritten prescriptions have been added to the computerised medication

Check all items issued to care home patients regularly to ensure that all discontinued medications are removed from the repeat template.

6. When to Refer Request for Repeat Prescription to the Prescriber All requests that cannot be issued, as detailed previously should be referred to the prescriber and an audit trail maintained to ensure these items are followed up. Dose changes

The instruction on the screen should always be specific and clear. The use of “as directed” is not recommended. Authorisations Items that reach their maximum number of issues must be re-authorised by the prescriber

before a prescription can be given to the patient. The prescriber must consider if the item can be re-authorised with reference to the patient notes, or if the patient needs to attend for a medication review. If the patient is due for a review, one month’s supply may be re-authorised by the prescriber. Ideally all repeats for an individual patient should have the same re-authorisation date, which should link with their medication review. Non-Compliance

Any concerns with under or over ordering of medication should be raised with the prescriber. Items not requested for a period of time e.g. six months, should be referred to the prescriber for confirmation to proceed, as they may be seasonal medicines or may be used on a ‘when required’ basis. If a patient is taking a medicine ‘when needed’ the quantity and the directions/frequency on the repeat should reflect this. High risk medicines

Any medicine considered ‘high risk’ should be flagged up to the prescriber before a repeat prescription is issued. Each practice should agree a list of medicines that will be treated in this way but suggested groups are:

Medicines which require frequent monitoring e.g. Lithium Disease-modifying anti-rheumatic drugs (DMARDS) e.g. Penicillamine

Warfarin

Methotrexate

Specialist drugs under hospital monitoring. 7. Adding Hospital Discharge / Outpatient Appointment Medication to Repeat

When a discharge or outpatient letter is received regarding new medication or changes to existing medication, this should be reviewed by the patient’s prescriber and items should be added to the repeat screen by the patient’s prescriber if appropriate. Check the following:

Check new or changed items against the patient’s current repeat template for duplication of therapeutic agents and interactions.

Check that the item(s) concerned are appropriate for repeat status.

The prescriber should refer requests for medicines not suitable for prescribing in primary care back to the secondary or tertiary care consultant. Traffic light status can be


checked on the Nottinghamshire Joint Formulary at www.nottinghamshireformulary.nhs.uk .

If the medicine is supplied by the hospital, the medication needs to be added to the patients’ medication list to allow interactions to be identified. Please see appendix for details

Take care to avoid transcription errors. Systems should be in place to ensure patients receive any new medicines in a timely manner.

Items not listed on the computer system (with no agreed read codes.)

Requests for these products must be referred to the prescriber. Details of the request must be recorded in the patient’s notes and added to the computer system record when the item is added or read code developed. 8. Medication Reviews All patients should receive a formal medication review by a healthcare professional on an annual basis (6 months for patients over 75 years on four or more repeats). An efficient recall system must be put in place to ensure that all patients attend their review. Please take care not to record a medication review read code where this has not occurred (e.g. if using SystmOne, ensure that the medication review box is unticked when amending medication details) as this may result in the patient not being called for annual medication review. A medication review can take place either face to face or over the telephone, depending on the preferred method of the practice. During the review all medication should be reviewed for continued need and discontinued where appropriate. Discontinued medicine should not continue to appear on the prescription counterfoil or repeat template. 9. Controlled Drugs (CDs) Issuing Repeat Prescriptions for controlled drugs

It is good practice that only prescribers issue repeat prescriptions for CDs to ensure that CDs are reviewed before each issue. Prescriptions for controlled drugs must comply with legal requirements.

An example of a management system in a GP practice would be that a prescription for a CD can be printed off by a prescription clerk and presented to the GP for signing, but the GP must stop and consider, on a case by case basis, whether they wish to call the patient in for review before issuing another prescription / whether the frequency of the request for this item is as they would expect etc.

A practical way of achieving this may be to include a management system in the practice repeat prescribing policy that ensures that when a prescription clerk prints off a prescription for a CD item that they cover the signature box with a coloured removable sticker or highlight the area, so that GPs can easily identify these prescriptions amongst many presented, and take the appropriate action.

It is recommended that prescriptions for CDs in schedules 2, 3 or 4 should be limited to a supply of 28 days.

http://www.nottinghamshireformulary.nhs.uk/


Mailing Prescriptions for Controlled Drugs National Prescribing Centre (NPC) CD guidelines state that CDs should not routinely be sent via mail. This may be considered appropriate in the case of treating drug addiction as it is not always desirable to hand the patient the prescription. However, it is advisable to have a procedure in place that includes a risk assessment. 10. Implementation and Review

The repeat prescribing procedure should be implemented in the practice supported by ‘in practice’ training of the reception staff on a regular basis to take account of staff turnover. The practices’ system and procedure should then be reviewed on an annual basis by the Practice Manager. This will address training issues and investigate areas for improvement. Patients should be informed of the practice repeat prescribing system and understand their responsibilities in the process. This can be included in the practice leaflet and covered during the registration process for new patients.

References

GMC. Good practice in prescribing and managing medicines and devices. April 2011 (Draft for consultation) National Prescribing Centre (NPC). 10 top tips for GPs, Strategies for safer prescribing. 2011. NPC. A guide to good practice in the management of controlled drugs in primary care (England).Third edition. December 2009 Adapted from NHS Nottinghamshire County Repeat Prescribing Procedure, March 2012. Written by Nottingham West CCG Medicines Management Team, May 2015. Review Date: May 2017.


Appendix 1 How to add regular medications prescribed and dispensed in secondary care to a GP clinical system so that interactions flag up when prescribing.

SystmOne – option A


SystmOne – option B

Retrieve the patient record

Either:

o Right-click on the ‘Repeat Template’ node in the clinical tree and select New

Repeat Template from the right-click menu, or

o Right click on an existing repeat on the Repeat Template and select New

Repeat Template from the right-click menu, or

o Click the ‘bottle with a +’ button at the top of the repeat template view

Complete the field as appropriate and under dose add

o DO NOT ISSUE, hospital supplies xmg day/month or

o DO NOT ISSUE, hospital supplies exact dose not known

Set the quantity to 1

Add TO BE ISSUED BY HOSPITAL in the script note

Set issue duration to 1 day

Unclick the ‘maximum issues’ box

Unclick the ‘patient can initiate issues’ box

Click OK

The medication is now added to the repeat template


Emis Web – option A only

Emis Web From Home Screen click on the Emis bubble and select Care Record | Medication

Select Add Drug from top left hand corner of screen


Add the drug name and in the dosage instructions add “Do not issue – hospital supplies exact dose not known”

Under quantity insert ‘1’ Under authorised issues, insert ‘1’

Click ‘Issue’

Select ‘Change all’ and pick ‘Hospital (no print)’ from drop down menu.


Click Approve and Complete When you try to prescribe you get the following warnings:

repeat prescribing procedure€¦ · 1. requests for repeat medicines requests should be sent to...

Documents