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The prescription should be written in full form and filled in the department, name, gender, age, date, etc. The drug name, drug dosage form, specification, dosage and usage in the body of the prescription must be clearly written, and self-created drugs must not be used.
Format of the standard prescription
The general condition and clinical diagnosis of the patient should be clear and complete, and consistent with the medical record. Each prescription is limited to one patient. The handwriting is clear and must not be altered, and if it needs to be modified, it shall be signed at the place of modification and the date of modification shall be indicated.
Prescriptions are always written in standard Chinese or English names.
According to Article 2 of the Measures for the Administration of Prescriptions, prescriptions refer to those prescribed by registered licensed physicians and licensed assistant physicians. It is hereinafter referred to as the pharmacy professional and technical personnel who are prescribed by physicians for patients in diagnosis and treatment activities and who have obtained the qualifications for professional and technical positions in pharmacy. Hereinafter referred to as the pharmacist review, dispense, check, and serve as the patient's medication voucher for the medical documents.
Prescriptions include prescriptions for medications in the wards of medical institutions. A prescription is a written document for a doctor to use drugs on a patient, and is the basis for pharmacists to dispense drugs, and has legal, technical and economic responsibilities.
The 2007 edition of the Prescription Management Measures promulgated by the Ministry of Health stipulates that when physicians use computers to issue and transmit ordinary prescriptions, they should print out paper prescriptions at the same time, and the format is consistent with the handwritten prescriptions.
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1 Standard prescription format.
RP: drug name (dosage form) unit dose total.
sig.Unit dose Usage Number of times per day.
Example 1: rp:injPenicillin sodium 800,000 U 6 sig800,000 U bid (skin test) Example 2: RP: cefaclor extended-release capsules.
sig. bid
2 Simple prescription format.
RP: Drug name (dosage form) Unit dose Usage Number of days Number of days Example 1: RP: injPenicillin sodium 800,000 u3 bid
Example 2: RP: 1 box of cefaclor extended-release capsules.
2 capsules bid
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The prescription format consists of three parts:
1. Preamble (including the name of the medical, preventive and health care institution, prescription number, fee, patient's name, gender, age, outpatient or inpatient medical record number, department or ward and bed number, clinical diagnosis, date of issuance, etc., and may add items required by the specialty).
2. The text (marked with RP or R, and then write the name, specification, quantity, and usage and dosage of the drug in the next line).
3. Postscript (signature of the physician or special signature, the amount of the drug and the signature of the pharmacy professional and technical personnel who review, dispense, check and issue the drug).
Rules: The general items of the patient in the prescription record should be clear, complete, and consistent with the medical record; Each prescription is limited to one patient; The handwriting of the prescription should be clear and should not be altered. If there is any amendment, it must be signed and dated at the amendment site; Prescriptions are always written in standard Chinese or English names.
A maximum of 5 medicines can be prescribed per prescription, and Chinese and Western medicines cannot be prescribed on one prescription. The name of the drug should be written with the generic name of the drug, and the brand name of the drug can be added in parentheses.
Prescription standard format.
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1. Preface. Including the name of the medical, preventive and health care institution, prescription number, fee, patient's name, gender, age, outpatient or inpatient medical record number, department or ward and bed number, clinical diagnosis, date of issuance, etc., and may add items required by the specialty.
2. Text. It is an important part of the prescription, which is marked by RP or R (abbreviation of Latin recipe "please take"), and lists the name, specification, quantity, usage and dosage of the drug. The prescription of Chinese medicine decoction pieces should list the name, quantity, decoction method and dosage of decoction pieces.
3. Afterword. The signature of the physician or the signature of the special signature, the amount of the drug and the signature of the pharmacy professional and technical personnel who review, dispense, check and issue the drug.
At present, physicians in medical institutions use the above regulations to write prescriptions, and write the patient's complaints, symptoms, pulse, physician's diagnosis, and treatment methods on the medical history card for investigation and follow-up.
Acquisition of prescribing rights:
1. Licensed physicians: Registered licensed physicians obtain the corresponding prescription rights at the place of practice.
2. Practicing assistant physicians: Prescriptions issued by registered practicing assistant physicians in medical institutions shall be signed by the licensed physician at the place of practice or stamped with a special signature before they are valid. Registered practicing assistant physicians who independently engage in general practice activities in medical institutions in townships, ethnic townships, towns, and villages may obtain the corresponding prescription rights at the registered practice location.
3. Probationary personnel: The prescription issued by probationary personnel shall be reviewed by a licensed physician with the right to prescribe in the medical institution where they are located, and signed or stamped with a special signature before it is valid.
4. Trainee physicians: Trainee physicians shall be granted the corresponding prescription rights after the actual situation of their professional work is determined by the medical institution receiving the training.
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The prescription writing format consists of three parts: the preface, the main text, and the afterword.
1.Preface: including the name of the medical, preventive and health care institution, prescription number, fee, NCMS medical insurance number, patient's name, gender, age, outpatient or inpatient medical record number, department or ward bed number, clinical diagnosis, date of issuance, etc.
2.Text: Marked with RP or R, the name, specification, quantity, usage and dosage of the drug are listed.
3.Postscript: the signature of the physician, the amount of the drug, and the signature of the pharmacy professional and technical personnel who review, dispense, check and dispense the drug.
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1 Standard prescription format. RP: drug name (dosage form) unit dose total.
sig.Unit dose Usage Number of times per day.
Example 1: rp:injPenicillin sodium 800,000 U 6 sig800,000 u bid (skin test).
Example 2: RP: Cefaclor sustained-release capsule capsules.
sig. bid
2 Simple prescription format. RP: Drug name (dosage form) Unit dose Usage Number of days Number of days Example 1: RP: injPenicillin sodium 800,000 u
3 bids
Example 2: RP: 1 box of cefaclor extended-release capsules.
2 capsules bid
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