Medical Mutual Insurance Company of Maine
Frequently Asked Questions related to risk management.

Risk Management » Practice Tips

April 2007

Medication: Prescription and Prescription Refill Process

A review of claims data provided by the Physicians Insurers Association of America (PIAA) has indicated the second most frequent claim filed against physicians involves prescription medication.  The drug classes most frequently involved in the claims reviewed were: antibiotics, glucocorticoids and narcotic/non-narcotic analgesics/narcotic antagonists. 

The following risk management issues were identified in the claims reviewed:

The American Hospital Association has listed the following as contributing factors to medication errors: 

All of the risk management issues discussed above are within the physician and the physician staff's control to prevent through a well defined and well managed office system for patient prescriptions and prescription refills.

The patient prescription and prescription refill process is one of the many physician office systems which require a written process that is followed by the physician, the physician's office staff and the practice's patients.

A policy should be developed which outlines the prescription and prescription refill policy and procedure of the office practice.  State and Federal Regulations regarding pharmaceutical prescribing should be followed when developing and implementing the policy.  If the practice is going to offer its patients medication samples, that process should also be outlined in the policy with consideration given to state and federal regulations.  Rural health centers, federal qualified rural health centers or practices owned by a hospital may have additional State and Federal Regulations that govern their distribution of sample medications which are not applicable to privately owned physician practices.

The following risk management suggestions should be considered when developing an office practice policy and procedure for patient prescriptions and prescription refills.

  1. All patients who are prescribed prescription medications should have a current medical history.

  2. Medication allergies should be documented in the appropriate area of the patient medical record.  If the patient has no known allergies, "no known allergies" or NKA should be written in the area to indicate the patient has no known allergies.  A medication allergy alert sticker should be prominently placed on the exterior of the patient medical record with the patient's allergy information documented on the allergy alert sticker.  If there are "no known allergies" again NKA should be written on the allergy alert sticker.  The patient should be asked about their allergy history at each patient visit and whenever a prescription refill is requested.  The patient medical record should reflect current patient allergy information.  Areas designed to record allergy information should not be left blank.

  3. Medications, including over the counter medications, herbal supplements and nutritional supplements should be documented in the patient medical record.  Questions regarding the effectiveness, usage and any side effects of these medications and supplements should be documented in the patient medical record.

  4. Prior to prescribing any medications, or providing any medication refills, a review of the patient's medical history, allergy history and medication history including over the counter medications and supplements should be reviewed.  This review should be documented in the patient's medical record.  Any changes should also be noted in the medical record at that time. 

  5. All discussions with the patient regarding allergies, side effects, dosage, special procedures for taking medications and other related issues should be documented in the patient's medical record.  Any written information provided to the patient regarding the instructions and adverse reactions of medications prescribed should be noted in the patient's medical record.

  6. A medication flow sheet located at the front of the patient's medical record should provide the following summary information: Patient name; Allergy alert information; Current medications and supplements; Date medication prescribed; Medication; Dosage; Number of pills; Number of refills; Any reactions noted. This information should be kept current for each patient to serve as a reference for the provider.

  7. When writing a prescription, limit each prescription to one medication.  Circle your name on the preprinted prescription pad.  Assure there is a correct telephone number and address for the practice.  Date the prescription.  Provide concise dosage information.  Provide the patient's name, age and if applicable weight.  Provide clear and specific directions, as most medications have recommended dosing regimens.  Specify the therapeutic duration.  The number of pills prescribed should match the patient's treatment plan.  Do not prescribe for possible recurrences of acute episodes.  It is also beneficial to write the indication on the prescription.  Write the number of refills, if any. 

  8. Document the patient's prescription in the patient's medical record.
    • Orders for new medications and medication refills should be recorded in the patient record and signed off by the provider with prescriptive authority to denote authorization.
    • All new medication orders should be specifically authorized by a provider with prescriptive authority prior to transmitting to pharmacy. If medications are refilled per protocol, follow recommendations in the Practice Tip entitled Medication Adjustment by Protocol & Medication Refill by Protocol.
    • All statutory requirements for prescribing controlled substances should be followed. Documentation should support the evaluation of the patient and indicate the reason for the medication prescribed. A comprehensive treatment plan which includes any patient consultations should be present in the patient’s medical record. Documentation of periodic review of the patient’s treatment plan, patient status, patient outcomes to the treatment prescribed and rationale for treatment plan changes should be clearly documented in the patient’s medical record.
    • Prescriptions should be clearly documented in the patient’s medical record, include the following: the date, the drug prescribed, the amount prescribed and the patient instructions.

  9. Telephone prescription refill requests should be filled only after the patient's medical record has been reviewed and any change in the patient's condition has been noted.  Verify allergy information in the patient's medical record is current, verify the patient's current and recent medication history, verify the patient's over the counter and supplement habits.  Document this reviewed information in the patient's medical record.  If the patient has not been seen in the past twelve months or if there has been a change in the patient's condition which indicates an office visit is needed, the patient should be seen by a the provider prior to authorizing a prescription refill to assure the prescription requested is appropriate.

  10. When the physician office practice dispenses sample medications to its patients, the practice is acting as a pharmacist and is required to follow state and federal pharmacy regulations.  The patient should receive written instructions on how to take the medication.  A copy of the written instructions to the patient should be placed in the patient's medical record.  Written instruction should include the name of the physician, the name of the patient, the date the sample was dispensed, the name and strength of the drug, the address and telephone number of the practice.  All discussions with the patient regarding allergies, side effects, dosage, special procedures for taking medications and other related issues should be documented in the patient's medical record.  Any written information provided to the patient regarding the instructions and adverse reactions of medications prescribed should be noted in the patient's medical record.

The following tips for preventing medication errors are suggested by Family Practice Management:

Resources/References: 

Medical Mutual's "Practice Tips" are offered as reference information only and are not intended to establish practice standards or serve as legal advice. MMIC recommends you obtain a legal opinion from a qualified attorney for any specific application to your practice.