Prescribing Instructions for Medicines

General Advice

1. Prescription writing and delivery:
   • Prescribers may only prescribe for patients in the care of Health New Zealand Canterbury (HNZ).
   • Prescribers must use approved prescription forms, electronic or paper.
   • Where available, electronic prescribing and delivery to the pharmacy is preferred.
   • Faxing is the least preferred option for prescription delivery. If faxing or providing paper prescriptions, ensure printer settings are changed to one-sided printing before printing and/or faxing.
2. Information that must be made known to the patient:
   • Any changes to therapeutic regimen during admission, and why (e.g. medicines stopped, started, and any changes to doses).
   • Any proposed changes (e.g. reducing dose of prednisone).
   • Any monitoring required (e.g. INR, digoxin concentrations).
3. Funding issues:
   • Pharmac does not fund all medications for use in the community. If unsure, ask the ward pharmacist. Alternatively, information about medicine funding is available in the Pharmac Pharmaceutical Schedule (Section H for hospital use; and Section B for community use).
   • Some medicines require a request to Pharmac for "special authority" approval in order to be funded – see www.pharmac.health.nz.
   • Apply for Special Authority.
     • Apply for electronic "special authority" (new application) for immediate authorisation of special authority medicines (sign-up needed).

       The website is sometimes not available. Easiest path is to try again later. If that is not practical, see third bullet about secure email option.
       If there is an issue with the Ministry of Health’s security certificate for this site, you will receive the “This site is not secure” message. Click on “More Information” and “Go on to the web page (not recommended)” and you will be able to proceed.

     • Most special authority items are processed immediately. Contact the ward pharmacist if there is an anticipated problem with community supply of the medicine.
     • If unable to apply electronically, apply by completing the relevant paper form and discuss with the ward pharmacist.
     • If the patient meets the ‘intent’ of the Special Authority criteria but not the exact listed criteria, consider applying for a waiver. You cannot do this via the electronic Special Authority system. Download the form and complete as much as possible. Explain where the individual does not meet the criteria and why they cannot. Email to waivers@pharmac.govt.nz. More detail is available here.
4. The patient or caregiver should be confident about the prescribed medicines aided by:
   • Verbal counselling from doctor, pharmacist, or nurse.
   • Patient Information Leaflets (PILs).
   • Providing or updating the patient's yellow medications card. Discuss with ward pharmacist or nurse.
   • Employing a compliance aid e.g. blister pack when appropriate. Discuss with ward pharmacist.
   • Access to culturally appropriate information. Some patients may not be able to take some medicines due to cultural or religious beliefs. Not everyone from a particular culture or religion has the same beliefs. However, medicines containing alcohol or derived from animal products are examples. For more information, see Religious, Cultural, and Other Considerations.

     Be aware of the impact of the patient's religious and cultural differences with regards to medicine compliance. Patients may:

     • have different expectations regarding obtaining and dispensing medicines, e.g. being able to buy antibiotics themselves.
     • have difficulty complying with when and how to take medicines due to religious beliefs, e.g. during periods of fasting. See:
       • University of Waterloo – Ramadan Fasting and Medications
       • Royal Australian College of General Practitioners – Diabetes Management During Ramadan
     • be unable to take some medicines due to religious or other beliefs and practices because they contain alcohol or are derived from animal products, e.g. gelatin in colecalciferol capsules.

       Gelatin

       Gelatin may be derived from beef that is halal-certified. This may be acceptable to a Muslim patient but not to a vegan patient.

       • Contact the pharmacist or medication information service for information about medicines when the patient has specific requirements about content and origin.
       • Give the patient data sheets and consumer medicines information (CMI) leaflets. Some patients may wish to contact the manufacturer directly.
       • Patients may be prepared to self-fund other medicines options when they have specific requirements. Discuss with the patient about the benefit the medicine may provide, as well as the risk of no treatment, to support them when they are deciding whether to accept a medicine.
       • See also:
         • Prescriber – Religious Constraints on Prescribing Medication
         • Queensland Department of Health – Medicines/Pharmaceuticals of Animal Origin.

     Not everyone has the same beliefs. Ask the patient, and encourage them to speak with their own religious leaders, e.g. the Imam. MuslimMed aims to provide Islamic guidance on contemporary issues related to healthcare (in the United States).

5. Ensure an accurate and recent record of body weight for children; and round the dose to the nearest whole number.
6. Prescriptions should always be clear:

   	✔	✘	Reason:
   	10 mg	10mg	10mg may look like 100g
   	2 mg	2.0 mg	2.0 mg may look like 20 mg
   	0.5 mg	.5 mg	.5 mg may look like 5 mg
   	UNIT(S)	U or u	U may look like 0
   	MICROGRAMS	μg, mcg	μg may look like mg
   	ONCE DAILY	OD, D or QD	od may look like bd, d may look like 1d (1 dose), qd may look like qid (4 times a day)
   	NANOGRAM	ng	ng could be mistaken for mg
   	MILLIMOLE or MMOL	milliequivalent or mEq	milliequivalent could be confused with millimole
   	SUBLINGUAL	SL	SL could be mistaken for SC
   	SUBCUT	SC	SC could be mistaken for SL
   	QID	QDS	qds could be mistaken for daily
   	L	l	I could be mistaken for 1 (one)
   	The following Latin and other abbreviations are acceptable:
   	BD	= twice daily	IM	= intramuscular
   	Q"X"H	= every "x" hours	IV	= intravenous
   	PRN	= as required	SUBCUT	= subcutaneously
   	TDS	= three times a day	PO	= oral
   	QID	= four times a day	PR	= rectal
   	MANE	= in the morning	TOP	= topical
   	NOCTE	= at night	INH	= inhaled

Inpatient Charting

General advice for inpatient prescribing

• There is a dual method of prescribing – electronic and paper. Where available, electronic is preferred unless not safe (e.g. complex infusions).
• Always check any updated allergy status before prescribing. For more information see the Adverse Drug Reaction guideline.
• Use of medicines within hospitals should be from the Hospital Medicines List (HML). See this guidance if using medicines not on the HML: Medicine Use Outside Hospital Medicines List Restrictions (Non-HML NPPA).

  All New Zealand hospitals are required to use medicines on the Pharmac Hospital Medicines List (HML). Occasionally there are good reasons to treat a patient with a medicine that is not on the HML or use a medicine outside of HML indication restrictions. Clinicians who wish to prescribe outside the HML for an individual patient whose clinical circumstances are exceptional need to apply for approval using a Named Patient Pharmaceutical Assessment (NPPA) application. The process at Te Whatu Ora Waitaha Canterbury is summarised in the flowchart below.

  Access the flow chart on PRISM.

  

• Prescriptions should use the generic medicine name when there is only one active ingredient. Insulin is an exception which must be prescribed with brand.

Electronic prescribing (MedChart)

Enter and/or update adverse drug reactions (Allergies and Intolerances box) on MedChart.

• Follow MedChart training and help advice found in MedChart in Reference Viewer.

• Some prescriptions are always on paper (e.g. insulin infusions) – refer to prescribing guidance below for paper drug charts.
• Use "Chart Exists" in MedChart to highlight medicines prescribed elsewhere.
• Patients who have been admitted through the Emergency Department (ED), or transferred from a procedural area may have a paper drug chart (National Medication Chart). Check before prescribing or administering in MedChart.
• Cancer chemotherapy is usually prescribed in MOSAIQ by Haematology/Oncology consultants/senior registrars (not MedChart).

Paper drug chart prescribing

• Prescribe on a National Medication Chart.
  • National Medication Charts are used in ED and most procedural areas (e.g. interventional radiology).

Enter and/or update adverse drug reactions (Drug Reactions box) on National Medication Charts.

• The patient's name must be clearly indicated.
• On the National Medication Chart, prescriptions must be signed by the prescriber and accompanied by the prescriber's name printed legibly and in CAPITALS.
• Write the medicine name in CAPITALS.
• To change prescriptions, cease and re-chart (e.g. if changing dose).
• Prescriptions should use the generic medicine name when there is only one active ingredient. Insulin is an exception which must be prescribed with brand.
• Do not abbreviate the name of any medicine or chemical because the wrong medicine may be given, e.g. MTX could be methotrexate or mitoxantrone.
• Use of medicines within hospitals should be from the Hospital Medicines List (HML). See this guidance if using medicines not on the HML (including Named Patient Pharmaceutical Assessment (NPPA)).

  All New Zealand hospitals are required to use medicines on the Pharmac Hospital Medicines List (HML). Occasionally there are good reasons to treat a patient with a medicine that is not on the HML or use a medicine outside of HML indication restrictions. Clinicians who wish to prescribe outside the HML for an individual patient whose clinical circumstances are exceptional need to apply for approval using a Named Patient Pharmaceutical Assessment (NPPA) application. The process at Te Whatu Ora Waitaha Canterbury is summarised in the flowchart below.

  Access the flow chart on PRISM.

  

All Outpatient and Discharge Prescriptions

Discharge prescribing is part of the writing of the discharge summary, in Health Connect South.

See Writing Discharge Summaries – Hints and Tips on Hospital HealthPathways.

1. Prescription writing and delivery:
   • Where possible, write and send prescriptions to the patient's pharmacy electronically. For instructions on how to send electronic prescriptions, see generating electronic prescriptions (HCS prescription guides) on the Health New Zealand (HNZ) Canterbury intranet.
   • Exceptions to electronic prescription writing and delivery are:
     • Pharmacies outside of HNZ Canterbury.
       • Pharmacies that cannot receive prescriptions electronically via ERMS (e.g. outside of HNZ Canterbury) should have prescriptions delivered by email.
         • When emailing prescriptions, use your email address and ensure that you are easily identifiable and contactable (provide a contact telephone or pager number).
         • Faxing prescriptions and providing paper prescriptions to patients are the least preferred options – however, it may be required for patients filing prescriptions in other DHBs.
         • If faxing or providing paper prescriptions, ensure printing settings are changed to one-sided printing before printing and/or faxing.
     • Hospital supply of medications to use in the community.
       • On discharge, most patients who need supply of medications will have a prescription as described above. Exceptions are:
         • In some specific situations, medications will be dispensed by the hospital pharmacy. Discuss with your ward pharmacist or dispensary (ext 88399).
         • Out of hours, a doctor may dispense a quantity from ward stock according to the Take Home Medications policy. Nurses cannot dispense medications for leave or discharge. For more details, see the Out of hours guidance and Dispensing from Ward Stock Policy.
         • In some areas, a doctor may prescribe and supply a medicine (such as single doses for before surgery in pre admission clinics). For more details, see the Dispensing from Ward Stock Policy.
     • Controlled Drugs (CD) prescribing summary.

       Prescribing summary

       CD Class	Example	CD form*	ERMS# + post	Max. qty. script	Max. qty. dispense
       A	cocaine	✔	✘	1 month	1 month
       B opioid	morphine	✔	✘	1 month	10 days (+ repeats)
       B non-opioid	methylphenidate	✔	✘	3 months	1 month (+ repeats)
       C specified	ketamine	✔	✘	1 month	1 month
       C non-specified + opioid	tramadol	✘	✔	1 month	1 month
       C non-specified + non-opioid	zopiclone	✘	✔	3 months	1 month (+ repeats)
       *CD form = handwritten on a triplicate-controlled drug prescription form H572. #ERMS = electronically 'written' and delivered to the patient's pharmacy via the Electronic Referral Management System (ERMS); then sign the original and post to the patient's pharmacy. Max. qty. script = maximum quantity per prescription. Max. qty. dispense = maximum quantity per dispensing. Within these limits, the prescriber controls the total quantity supplied. The pharmacist controls the dispensed quantity and frequency.

     • Controlled drugs written on a triplicate-controlled drug prescription form H572.

       Class A, Class B (such as morphine and methylphenidate) and some specified Class C (including buprenorphine and ketamine) controlled drugs require a controlled drug prescription, which must:

       • be written on a triplicate-controlled drug prescription form H572 (see example prescription – these are found in controlled drug cupboards).
       • be entirely handwritten by the prescriber including patient name, NHI, and full physical address. Note that a PO Box is not acceptable. Do not use patient labels.
       • be written in CAPITALS.
       • if patient younger than 12 years old, include date of birth.
       • include medicine strength and formulation in words and figures. This includes specifying oral liquid strengths (e.g. 5 mg/mL). Underline and initial unusual doses for clarity.
       • include total quantity (rather than duration) in words and figures. Underline and initial unusual quantities for clarity. Note: PRN alone is not acceptable.
       • have a maximum quantity for opioids of one month. Prescribe 10-day supply for Class B opioids with up to 2 repeats; or 7-day with up to 3 repeats.
       • have a maximum quantity for non-opioids of three months. Prescribe 1 month with up to 2 repeats.
       • have maximum of two items per prescription. Cross out blank section if one item only required.
       • be signed by the prescriber and accompanied by the prescriber's name printed legibly and regulatory council number (e.g., MCNZ number); and dated.
       • include hospital address under Practitioner's Name (for example, "Christchurch Hospital" is not adequate. Write "Christchurch Hospital, 2 Riccarton Ave, Christchurch" or equivalent, depending on campus).
       • be given to the patient or caregiver to deliver to a community pharmacy. Give all three copies.
       • inform patient or caregiver that the prescription must be presented to a pharmacy within 7 days.
       • contact the pharmacy to ensure supply available for infrequently used medicine products or strengths.

       Note: methylphenidate and dexamfetamine also require prescription by a psychiatrist, or internal or palliative care specialist, or be on their written recommendation per Misuse of Drugs Regulations.

       Note: Class B Controlled Drugs cannot be written electronically and sent through ERMS. If these are prescribed in the Health Connect South ‘Prescription’ template the whole prescription will not send, creating a delay for the patient.

     • Controlled drugs written electronically and delivered to the patient's pharmacy via ERMS.

       Class C opioid medicines (such as codeine and tramadol) may be written electronically and delivered to the patient's pharmacy via ERMS. Additionally:

       • maximum quantity is 1 month. Underline and initial unusual quantities for clarity.
       • annotate in the Prescriber Notes to Pharmacy Field in Health Connect South that the prescription is a Class C controlled drug and that a signed copy is being posted.
       • print and sign a paper copy of the prescription.
       • post the signed paper prescription to the patient's nominated pharmacy. Do not give a paper copy to the patient or caregiver, if sent through ERMS.

       Class C non-opioids (such as diazepam and zopiclone) may be written electronically and delivered to the patient's pharmacy via ERMS. Additionally:

       • maximum quantity is 3 months. Prescribe 1 month with up to 2 repeats.
       • annotate in the Prescriber Notes to Pharmacy Field in Health Connect South that the prescription is a Class C controlled drug and that a signed copy is being posted.
       • print and sign a paper copy of the prescription.
       • post the signed paper prescription to the patient's nominated pharmacy. Do not give a paper copy to the patient or caregiver, if sent through ERMS.

       Note: If a pharmacy declines a Class C Controlled Drug prescription sent via ERMS, or requests it be signed and resent, there are two options for the prescriber. The prescription can be signed, scanned and either emailed to the pharmacy or manually loaded into ERMS.

2. Duration or quantity:
   • Prescribers control the total quantity of supply. The pharmacist and Pharmaceutical Schedule control the dispensed quantity and frequency in nearly all situations.
   • PRN medications must be prescribed with a quantity rather than duration, e.g. codeine PO 30 mg TDS PRN – 30 tablet supply. If this was prescribed as 30 days, the pharmacist would dispense 90 tablets which may be excessive and may promote abuse.
   • For long-term medicines that are new or need review by the GP, consider short durations, e.g. 2 weeks.
3. Funding issues:
   • Pharmac does not fund all medications for use in the community. If unsure, ask the ward pharmacist. Alternatively, information about medicine funding is available in the Pharmac Pharmaceutical Schedule (Section H for hospital use; and Section B for community use).
   • Some medicines require a request to Pharmac for "special authority" approval in order to be funded – see www.pharmac.health.nz.
   • Apply for Special Authority.
     • Apply for electronic "special authority" (new application) for immediate authorisation of special authority medicines (sign-up needed).

       The website is sometimes not available. Easiest path is to try again later. If that is not practical, see third bullet about secure email option.
       If there is an issue with the Ministry of Health’s security certificate for this site, you will receive the “This site is not secure” message. Click on “More Information” and “Go on to the web page (not recommended)” and you will be able to proceed.

     • Most special authority items are processed immediately. Contact the ward pharmacist if there is an anticipated problem with community supply of the medicine.
     • If unable to apply electronically, apply by completing the relevant paper form and discuss with the ward pharmacist.
     • If the patient meets the ‘intent’ of the Special Authority criteria but not the exact listed criteria, consider applying for a waiver. You cannot do this via the electronic Special Authority system. Download the form and complete as much as possible. Explain where the individual does not meet the criteria and why they cannot. Email to waivers@pharmac.govt.nz. More detail is available here.
4. Rest homes:
   • Liaise with the patient’s rest home to confirm their regular community pharmacy.
   • Rest homes often require a full prescription of all their regular medications.
   • Ceased or changed medicines must be clearly documented.
   • Medicines with variable dosing schedules must be clearly prescribed, for example, warfarin dosing until the next blood test.
5. Blister packs:
   • If a patient is usually prescribed blister packs and had changes to their medicines, this must be organised with their regular community pharmacy if open.
   • It is recommended to prescribe all regular medications to be included in a blister pack.
   • Blister packs take time to prepare and early liaison is necessary.
   • If the patient has medications at home that have been stopped or changed, encourage them to return these to their pharmacy.
6. Less commonly prescribed medicines and compounded liquids:
   • Some less commonly prescribed medicines and compounded liquids may not be readily available at all community pharmacies. Pharmacies may also not be able to order from suppliers after hours.
   • Early liaison with the community pharmacy is important to address any potential issues.
7. Funding:
   • Ensure discharge medications are funded in the community by checking the Pharmac Schedule (Section B) and special authorities (where required) are completed electronically.
   • Medications that are only funded in hospital on the HML must be supplied by the hospital pharmacy only (e.g. cefuroxime for indications other than endocarditis).
   • Contact the ward pharmacist for advice.
8. Special circumstances:
   • Palliative care: for discharge on subcutaneous syringe drivers, refer to the Palliative Care guidelines.
   • Opioid substitution: must not be prescribed on discharge, refer to the opioid substitution guidelines.
   • Home Intravenous Antimicrobials: to arrange referral, contact the Outpatient Parenteral Antimicrobial Therapy (OPAT) Service via the Infection Management Service on 027 702 4268 or via the switchboard.
     • If the patient is thought to be suitable for home intravenous antimicrobial therapy, the Infection Management Service or consultant will refer the patient to the OPAT Service.
     • Following referral, allow at least 24 hours for assessment, education, and to organise medication and district nurse referral. To confirm that the referral has been received by the OPAT Service, contact them on 027 290 0823.
     • Inform the patient, and clearly state in the discharge summary that the referral has been made. Do not write Outpatient prescriptions for the OPAT medicines. Medication charts for community use will be provided by the OPAT Service.

After-Hours Discharge and Community Prescribing

In addition to the general advice above, contact the patient's community pharmacy:

• Confirm if the patient’s regular community pharmacy is open.
  • Opening hours and contact details for after-hours pharmacies are available on Healthpoint.
  • Contact the pharmacy to confirm they will be available following patient discharge.

Funding:

• Ensure discharge medications are funded in the community by checking the Pharmac Schedule and special authorities (where required) are completed electronically.
• Medications that are only funded in hospital on the HML must be supplied by the hospital pharmacy only (e.g. cefuroxime for indications other than endocarditis).
• Contact the on-call pharmacist for advice out of hours.

Supply of hospital medicines to take home after hours:

• On discharge, most patients who need supply of medications will be given a prescription to fill at their community pharmacy when it opens. Out of hours, a doctor may dispense a quantity from ward stock in some specific situations.
  • Some medications are only dispensed by the hospital pharmacy. Contact the on-call pharmacist for advice out of hours.
  • A doctor may dispense a quantity from ward stock to provide necessary medication until the community pharmacy opens. Nurses cannot dispense medications for leave or discharge. For more details, see the Dispensing from Ward Stock Policy. To document in MedChart see also here.
  • In some areas, a doctor may prescribe and supply a medicine (such as single doses for before surgery in pre-admission clinics). For more details, see the Dispensing from Ward Stock Policy. To document in MedChart see also here.

Special circumstances:

• Home Intravenous Antimicrobials: This service is not available after hours. Contact Outpatient Parenteral Antimicrobial Therapy (OPAT) on 027 290 0823 to discuss options.

Topic Code: 132290

must be prescribed or recommended by a consultant.