Essential Components of a Prescription
A properly written prescription must include patient information, medication details, dosing instructions, and prescriber information to ensure safe and effective medication use.
Patient Information
- Full patient name, date of birth, and contact information must be included for proper identification 1
- Medical record number should be included when applicable, especially in hospital settings 2
- Patient's age and weight should be included for medications where dosing is weight-dependent 3
Medication Details
- Generic name of the medication should be used to avoid confusion and reduce costs 4
- Brand name may be included when bioequivalence is a concern or when specifically required 4
- Medication strength must be clearly specified (e.g., mg, mcg, %, etc.) 5
- Dosage form should be specified (tablet, capsule, liquid, etc.) 4
Dosing Instructions
- Dose amount must be clearly specified using appropriate units 3
- Frequency should use explicit time periods (e.g., "morning" or "8 AM") rather than vague instructions like "twice daily" to improve patient understanding 6
- Route of administration must be specified (oral, topical, etc.) as this is frequently omitted (present in only 0.5-0.8% of prescriptions) 5
- Duration of treatment should be included to prevent indefinite use of medications intended for short-term use 5
Prescriber Information
- Prescriber's full name, credentials, and contact information 1
- DEA number for controlled substances 7
- Prescriber's signature to validate the prescription 7
Additional Important Elements
- Indication for use should be included to help pharmacists and patients understand the purpose of the medication 8
- Special instructions for administration (e.g., "take with food," "do not lie down for 30 minutes after taking") should be included when relevant 8
- Refill information must be clearly stated, especially for chronic medications 4
- Date the prescription was written 7
Best Practices for Clarity
- Use clear, explicit language rather than medical abbreviations or Latin terms that patients may not understand 6
- Write in legible handwriting or use electronic prescribing to avoid misinterpretation 4
- Include both the brand and generic names when appropriate to avoid confusion 4
- Specify exact timing rather than frequency (e.g., "take at 8 AM and 8 PM" instead of "take twice daily") 6
Common Pitfalls to Avoid
- Omitting route of administration, which occurs in over 99% of prescriptions 5
- Failing to specify duration of treatment, which occurs in over 99% of prescriptions 5
- Using abbreviations that could be misinterpreted (e.g., "qd" instead of "daily") 3
- Providing vague dosing instructions that lead to patient confusion and potential medication errors 6
- Not including indications, which are often omitted from prescription labels (included in only 38% of labels) 8
Ensuring Patient Understanding
- Provide verbal instructions in addition to written prescriptions 9
- Confirm patient understanding by having them repeat back dosing instructions 9
- Provide written patient education materials in the patient's preferred language 3
- Consider literacy level when providing instructions, as readability scores significantly differ with education level 5