How to Write a Prescription
A properly written prescription must include specific patient identifiers, prescriber information, drug details (name, strength, dosage form, quantity, dose, frequency, route, duration), and legally required elements to ensure patient safety and prevent medication errors.
Essential Patient Information
Every prescription must verify and document:
- Two patient identifiers (name and date of birth, or name and address) at the time of entering and dispensing the prescription 1
- Patient's complete address 2
- Patient's age and sex 2
Required Prescriber Information
The prescription must contain:
- Prescriber's full name and signature 2
- Prescriber's professional qualifications 2
- Medical registration number 2
- Contact information for follow-up questions 1
Common pitfall: Studies show that prescriber's name, qualification, and registration number are omitted in 85-99% of prescriptions reviewed, creating legal and safety issues 2.
Complete Drug Information
Mandatory Drug Details
Each medication entry requires:
- Generic drug name (preferred) with correct spelling 3, 2, 4
- Strength of the medication (e.g., 10 mg, 500 mg) 2
- Dosage form (tablet, capsule, liquid, injection) 2
- Specific dose to be taken 2
- Frequency of administration (once daily, twice daily, three times daily) 2
- Route of administration (oral, topical, intravenous) 2
- Duration of treatment 2, 5
- Total quantity to dispense 2
Critical safety note: Dosage form, route, and duration are frequently omitted—missing in 12%, 63%, and over 99% of prescriptions respectively in one study 2. These omissions create dangerous ambiguity.
Prescription Symbol and Format
- Include the symbol "Rx" at the beginning of the drug order 2
- Avoid non-official abbreviations that can be misinterpreted 2
- Ensure legibility—illegible handwriting remains a persistent cause of medication errors and patient harm 6
Special Instructions and Patient Education
Administration Details
Specify:
- Timing relative to meals (with food, without food, on empty stomach) 1
- Special handling instructions (take whole, do not crush, refrigerate) 1
- What to do if a dose is missed 7
Patient Communication Requirements
Before dispensing, ensure:
- Formal patient education session occurs with an experienced clinical educator covering drug name (generic and brand), dose, schedule, potential adverse effects, management strategies, treatment goals, and duration 1
- Written patient education materials in the patient's preferred language 1
- Legally required prescribing information is provided 1
- Patient understanding is verified through teach-back or similar methods 1
Safety Verification Before Dispensing
The prescriber or pharmacist must check:
- Appropriate diagnosis and indication for the prescribed medication 1
- Drug allergies documented and reviewed 1
- Drug interactions with current medications, including over-the-counter and herbal products 1
- Duplicate therapies in the patient's medication profile 1
- Correct drug, dose, and directions against the most recent provider note 1
Documentation and Follow-Up
Required Documentation
- Document all clinical encounters in the patient record (preferably electronic) 1
- Include systematic follow-up within 7 days of dispensing to assess adherence and toxicities 1
- Record any patient questions and responses 1
- Note any financial barriers affecting adherence 1
Refill Procedures
Before refilling:
- Review patient records for clinically relevant information (abnormal labs, prescription changes, latest progress note) 1
- Verify with prescriber and patient/caregiver before dispensing refills 1
- Do not refill unless explicitly verified 1
Computerized Systems
Strongly consider using computerized provider order entry (CPOE) systems to:
- Improve legibility and accuracy 4, 6
- Reduce prescribing errors 4
- Access electronic drug references for interaction checking 4
- Ensure standardized, complete information 6
Evidence shows that while electronic prescriptions are becoming more common, handwritten prescriptions remain prevalent and illegibility continues to cause delays in care and serious patient harm, including death 6.