What is the proper format for writing an Outpatient Department (OPD) prescription?

How to Write an OPD (Outpatient Department) Prescription

Every prescription must include three core components: patient identifiers (name, age, date of birth), complete drug information (generic and brand name, strength, dosage form, route, frequency, duration, and quantity), and prescriber details (name, qualification, signature, date, and contact information). 1

Essential Patient Information

• Verify patient identity using two identifiers (name and date of birth or address) before writing the prescription 1
• Document patient's OPD file number, age, gender, address, and contact number 2
• Record relevant allergies and current diagnosis on the prescription 1

Complete Drug Information Requirements

Each medication entry must specify:

• Generic and brand name of the drug 1
• Strength and dosage form (tablet, capsule, syrup, etc.) 2, 3
• Exact dose (e.g., "500 mg" not just "1 tablet") 1
• Route of administration (oral, topical, etc.) 3
• Frequency (e.g., "twice daily," not "BD") - avoid abbreviations 1, 3
• Duration of therapy (e.g., "for 7 days") 1, 3
• Total quantity to dispense 1, 3
• Specific instructions (with or without food, timing relative to meals) 1
• Indication for use - this reduces errors and improves patient understanding 3

Prescriber Information

• Include your full name, department, and qualification 2
• Add contact details for patient queries 1
• Date the prescription 2
• Sign legibly 2

Critical Safety Checks Before Writing

Before finalizing any prescription:

• Review the most recent clinical notes to validate the treatment plan 1
• Screen for drug interactions with current medications, including over-the-counter and herbal products 1
• Check for duplicate therapies in the patient's medication profile 1
• Verify appropriate dosing for the patient's age, weight, and renal/hepatic function 4
• Consider drug cost and discuss financial concerns that may affect adherence 1, 4

Common Pitfalls to Avoid

• Never use abbreviations that can be misinterpreted (avoid "OD," "BD," "HS") 1
• Avoid trailing zeros (write "5 mg" not "5.0 mg") and always use leading zeros (write "0.5 mg" not ".5 mg") 1
• Do not write prescriptions for concentrated or high-risk medications (like insulin, heparin) without double-checking dose calculations 1
• Never leave any field blank - incomplete prescriptions lead to dispensing errors 3

Patient Education Component

At the time of prescribing, you must:

• Provide verbal instructions on how to take each medication, including timing, food interactions, and what to do if a dose is missed 1, 5
• Explain potential adverse effects and when to contact you 1
• Give written patient information in the patient's preferred language whenever possible 1, 5
• Establish clear contact points for emergencies and non-urgent questions 1
• Document the education provided in the patient's medical record 1

Documentation Standards

• Record every prescription in the patient's medical record - electronic documentation is strongly preferred 1
• Document any patient questions about their therapy 1
• Note any financial assistance discussions or barriers to adherence 1

Follow-Up Planning

• Schedule reassessment within an appropriate timeframe based on the medication and condition 4
• Plan for monitoring of drug toxicity and laboratory tests as needed 1
• Establish refill protocols - do not authorize refills without verifying continued need with the patient 1