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This article will cover the following knowledge areas to prepare you for the Pharmacy Technician Certification Exam:

• Order entry process
• Intake, interpretation, and data entry
• Calculate doses required
• Fill process (e.g., select appropriate product, apply special handling requirements, measure, and prepare product for final check)
• Labeling requirements (e.g., auxiliary and warning labels, expiration date, patient specific information)
• Packaging requirements (e.g., type of bags, syringes, glass, PVC, child resistant, light resistant)
• Dispensing process (e.g., validation, documentation and distribution)

Terminology

To get started in this chapter, there are some terms that should be defined.

e-prescribing - E-prescribing is the computer-based electronic generation, transmission and filling of a medical prescription, taking the place of paper and faxed prescriptions. E-prescribing allows a physician, nurse practitioner, or physician assistant to electronically transmit a new prescription or renewal authorization to a community or mail-order pharmacy.

pharmacy benefits manager (PBM) - A PBM is a company that acts as an intermediary between the pharmacy and the insurance plan.

computerized prescriber order entry (CPOE) - Computerized prescriber order entry, also called computerized physician order entry, is a process of electronic entry of practitioner instructions for the treatment of patients under their care. CPOE systems are used for processing orders in institutional settings.

superscription - The superscription consists of the heading on a prescription where the symbol Rx is found. The Rx symbol comes before the inscription.

inscription - The inscription is also called the body of the prescription, and provides the names and quantities of the chief ingredients of the prescription. Also in the inscription you find the dose and dosage form, such as tablet, suspension, capsule, syrup.

signatura - The signatura (also called sig, or transcription), gives instructions on a prescription to the patient on how, how much, when, and how long the drug is to be taken. These instructions are preceded by the symbol “S” or “Sig.” from the Latin, meaning "write" or "label." Whenever translating the signatura into instructions for a patient, begin it with an action verb such as take, inhale, spray, inject, place, swish, or whatever other verb seems appropriate for the medication.

bank identification number (BIN) - On a health insurance card a BIN is a six digit number used to identify a specific plan from a carrier making it easier for the PBM to process your prescription online. No actual bank is involved in this part of the process, the name is a hold over from early electronic banking jargon.

dispense as written (DAW) codes - DAW codes are used to provide a quick explanation of whether or not a generic version of the medication is allowed to be dispensed, and if not then why and whom deemed the brand name product to be necessary. A DAW code of '0' applies to most prescriptions as they allow for generic substitution and patients are generally willing to receive the more affordable version. If a physician requires a specific medication to be dispensed, they will typically note this on the prescription. This is considered a DAW code of '1'. Sometimes a patient may request that they receive a brand name product even if a prescriber allowed for generic substitution. This would be classified as a DAW code of '2'. Other DAW codes are less frequently used. The following is a succinct list of the other DAW codes; 3 = substitution allowed - pharmacist selected product dispensed, 4 = substitution allowed - generic drug not in stock, 5 = substitution allowed - brand drug dispensed as generic, 6 = override, 7 = substitution not allowed - brand drug mandated by law, 8 = substitution allowed - generic drug not available in marketplace, and 9 = Other.

Prescription intake

Prescription intake, which is often the responsibility of a pharmacy technician, involves both the receipt of the initial prescription and, in a community pharmacy setting, gathering pertinent patient data.

Receiving the prescription

With respect to prescription intake the first thing to address is the means by which the medication itself arrives in the pharmacy. Prescriptions may arrive on a traditional prescription form (there are specific security requirements on this if the patient is using Medicaid), a fax or phone call from an appropriately licensed prescriber, e-prescribing in an outpatient setting, and computerized prescriber order entry (CPOE) in an institutional setting. These various means have various federal regulations associated with them and individual states may place additional restrictions on how they are used.

A written prescription should contain the following information at a minimum:

• the prescriber's name, address, and telephone number,
• if the order is for a controlled substance, the prescriber's DEA number,
• the patient's name, the date of issuance,
• the name of the medication or device prescribed and dispensing instructions (if necessary),
• the directions for the use of the prescription,
• any refills (if authorized),
• special labeling and other instructions, and
• the prescriber's signature.

The Medicaid Tamper-Resistant Prescription Pad Law has placed additional requirements on written prescriptions to help ensure the legitimacy of the prescriptions being received in the pharmacy. Since October 1, 2008 all Medicaid scripts must contain one or more industry recognized features from each of three categories of security as specified by the Center for Medicare and Medicaid Service (CMS).

Category One - One or More industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form.

• Void Pantograph background (Hidden Message Technology)
• Reverse Rx Symbol
• Micro Printing
• Artificial Watermark on back of script
• Coin Activated Ink

Category Two - One or More industry-recognized features designed to prevent the erasure or modification of information written on a prescription by the prescriber.

• Colored Shaded Pantograph background
• Toner Grip Security Coating
• Check and Balance" printed features such as "quantity" check boxes, and space to indicate "number of medications" written on prescription form

Category Three - One or More industry-recognized features designed to prevent the use of counterfeit prescription forms.

• Security Feature Warning Box and Warning Bands
• Security Back Printing
• Coin Activated Validation
• Batch Number identification
• Secure Rub Color Change Ink
• Consecutive Numbering

Physicians may, and often do, use these tamper-resistant prescriptions for their other patients as well.

Prescribers may send prescriptions to the pharmacy via a fax machine. The same requirements listed on written prescriptions apply for faxed prescriptions (although prescribers do not need to use tamper-resistant prescription pads for faxed orders), but their is an additional limitation. Schedule II medications may not be faxed under ordinary circumstances.

DEA has granted three exceptions to the fax prescription requirements for Schedule II controlled substances. The fax of a Schedule II prescription may serve as the original prescription as follows:

• A practitioner prescribing Schedule II narcotic controlled substances to be compounded for the direct administration to a patient by parenteral, intravenous, intramuscular, subcutaneous or intraspinal infusion may transmit the prescription by fax. The pharmacy will consider the faxed prescription a "written prescription" and no further prescription verification is required. All normal requirements of a legal prescription must be followed.
• Practitioners prescribing Schedule II controlled substances for residents of Long Term Care Facilities (LTCF) may transmit a prescription by fax to the dispensing pharmacy. The practitioner’s agent may also transmit the prescription to the pharmacy. The fax prescription serves as the original written prescription for the pharmacy.
• A practitioner prescribing a Schedule II narcotic controlled substance for a patient enrolled in a hospice care program certified and/or paid for by Medicare under Title XVIII or a hospice program which is licensed by the state may transmit a prescription to the dispensing pharmacy by fax. The practitioner (or their agent) may transmit the prescription to the pharmacy. The practitioner will note on the prescription that it is for a hospice patient. The fax serves as the original written prescription.

A phone order prescription (also called a verbal order), should include all the same information as a written prescription as the pharmacist will need to reduce it to writing to later be filed with the other prescriptions. Under ordinary circumstances, Schedule II medications may not be called in.

For Schedule II controlled substances, an oral order is only permitted in an emergency situation. An emergency situation is defined as a situation in which:

• Immediate administration of the controlled substance is necessary for the proper treatment of the patient.
• No appropriate alternative treatment is available.
• Provision of a written prescription to the pharmacist prior to dispensing is not reasonably possible for the prescribing physician.

In an emergency, a practitioner may call-in a prescription for a Schedule II controlled substance by telephone to the pharmacy, and the pharmacist may dispense the prescription provided that the quantity prescribed and dispensed is limited to the amount adequate to treat the patient during the emergency period. The prescribing practitioner must provide a written and signed prescription to the pharmacist within seven days. Further, the pharmacist must notify DEA if the prescription is not received.

E-prescribing has become a very common practice. Since 2007 pharmacies have been allowed to transmit prescriptions electronically using properly certified software (i.e., SureScripts) for most legend drugs. As of June 1, 2010 physicians and pharmacies are also allowed to transmit prescriptions for Schedule II, III, IV, and V medications. While this is a recent shift in federal law, some states may still prohibit e-prescribing for controlled substances.

Through the requirement of using computer programs that communicate through SureScripts to electronically prescribe outpatient prescriptions, SureScripts has the responsibility of authenticating both the receipt and delivery of the electronic prescription. E-prescribing also allows the prescriber to verify whether or not a particular medication is covered by the patient's pharmacy benefits manager (PBM)

Institutional settings are more likely to utilize CPOE (computerized prescriber order entry, also called computerized physician order entry) than e-prescribing. CPOE is a process of electronic entry of practitioner instructions for the treatment of patients under their care. These orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order. CPOE decreases delay in order completion, reduces errors related to handwriting or transcription, allows order entry at the point of care or off-site, provides error-checking for duplicate or incorrect doses or tests, and simplifies inventory and posting of charges.

Gathering patient data

When a patient first arrives at a community pharmacy the pharmacy team will need to gather/verify various important pieces of patient data including:

• gather drug and disease information,
• ensure that the pharmacy has the correct name, address, contact information, and any other pertinent data,
• document/update allergy information
• verify/update medication insurance information

In an inpatient setting, while a pharmacy will still want all this information to be completed, it is typically the responsibility of other departments.

Prescription translation

Once the prescription has entered the pharmacy, it becomes the responsibility of the pharmacy staff to decipher and fill the medication for the patient. This will likely require the translation of various medical abbreviations and some calculation to ensure that the proper quantity is being dispensed.

Abbreviations

Prescriptions have been obfuscated by a combination of Latin and English abbreviations (sometimes they even throw in Greek words). They are commonly used on prescriptions to communicate essential information on formulations, preparation, dosage regimens, and administration of the medication. There are approximately 20,000 medical abbreviations; instead of providing an exhaustive and meaningless list, this section will focus on the most common medical abbreviations that are necessary for interpreting prescriptions and performing calculations.

The following lists are broken into five categories including route, dosage form, time, measurement, and a catch all category simply named "other." The abbreviations can often be written with or without the 'periods' and in upper or lower case letters (e.g., p.o. and PO both mean 'by mouth'). The format on these lists will be to provide the abbreviation, followed by its intended meaning.

Route

aa - affected area
a.d. - right ear
a.s. - left ear
a.u. - each ear
IM - intramuscular
IV - intravenous
IVP - intravenous push
IVPB - intravenous piggyback
KVO - keep vein open
n.g.t. - naso-gastric tube
n.p.o. - nothing by mouth
nare - nostril
o.d. - right eye
o.s. - left eye
o.u. - each eye
per neb - by nebulizer
p.o. - by mouth
p.r. - rectally
p.v. - vaginally
SC or SQ - subcutaneously
S.L. - sublingually (under the tongue)
top. - topically

Some additional notes on these routes of administration are necessary. The abbreviation 'a.d.' if written without periods, ad, can also mean to or up to. Also, subcutaneously can be abbreviated as 'SC' or 'SQ'. While amongst health care professionals we would use the phrase sublingual as a route of administration, it may be necessary to translate 'SL' as 'under the tongue' for many patients.

Dosage form

amp. - ampule
aq or aqua - water
caps - capsule
cm or crm - cream
elix. - elixir
liq. - liquid
sol. solution
supp. - suppository
SR, XR XL - slow/extended release
syr. - syrup
tab. - tablet
ung. or oint - ointment

The abbreviation 'cm' can be translated as either 'cream' or 'centimeter'. Use context clues from the rest of the prescription to determine which translation is appropriate.

Time or how often

a.c. - before food, before meals
a.m. - morning
atc - around the clock
b.i.d. or bid - twice a day
b.i.w. or biw - twice a week
h or ° - hour
h.s. - at bedtime
p.c. - after food, after meals
p.m. - evening
p.r.n. or prn - as needed
q.i.d. or qid - four times a day
q - each, every
q.d. - every day
q_h or q_° - every__hour(s) (i.e., q8h would be translated as every 8 hours)
qod - every other day
stat - immediately
t.i.d. or tid - three times a day
t.i.w. or tiw - three times a week
wa - while awake

Measurement

i, ii, ... - one, two, etc. (often Roman numerals will be written on prescriptions using lowercase letters with lines over top of them)
ad - to, up to
aq. ad - add water up to
BSA - body surface area
cc - cubic centimeter
dil - dilute
f or fl. - fluid
fl. oz. - fluid ounce
g, G, or gm - gram
gr. - grain
gtt - drop(s)
l or L - liter
mcg or μg - microgram
mEq - milliequivalent
mg - milligram
ml or mL - milliliter
q.s. - a sufficient quantity
q.s. ad - add a sufficient quantity to make
ss - one-half (commonly used with Roman numerals to add a value of 0.5)
Tbs or T - tablespoon
tsp or t - teaspoon
U - unit
> - greater than
< - less than

Other

c - with
disp. - dispense
n/v - nausea and vomiting
neb - nebulizer
NR - no refills
NS or NSS - normal saline, normal saline solution
s - without
Sig or S - write, label
SOB - shortness of breath
T.O. - telephone order
ut dict or u.d. - as directed
V.O. - verbal order

Parts of a prescription

Traditionally, a prescription is a written order for compounding, dispensing, and administering drugs to a specific client or patient and once it is signed by the physician it becomes a legal document. Prescriptions are required for all medications that require the supervision of a physician, those that must be controlled because they are addictive and carry the potential of being abused, and those that could cause health threats from side effects if taken incorrectly, for example, cardiac medications, controlled substances, and antibiotics.

The following is a list of the parts of a prescription:

• Patient Information, which may include information such as name, address, age, weight, height, and allergies.
• Superscription, which is the 'Rx' symbol that we typically translate as, "Take thus."
• Inscription, which is the actual medication or compounding request.
• Subscription, or how much to dispense.
• Signatura, which is the instruction set intended for the patient.
• Date, this is when the prescription was written. prescriptions for medications and supply that are not considered controlled substances are good for up to 1 year from when the prescription was written.
• Signature lines, which is where the prescriber provides their signature and indicates their degree. Often, this is also where a prescriber may indicate their preferences with regard to generic substitution.
• Prescriber information, which includes the physician's name, practice location address, telephone number and fax number. This may also include the prescriber's NPI number and appropriate license numbers.
• DEA#, DEA numbers are required for controlled substances.
• Refills, which simply indicates how many refills may be supplied for a particular medication.
• Warnings, which are provided by the prescriber with the intention of emphasizing specific concerns.

So, if we look at a prescription for Patricia Pearson (see below), we can see that it is for Lipitor (atorvastatin Ca) 20 mg tablets, and that the patient is to receive 30 of them with 2 refills. The instructions to the patient would be, “Take 1 tablet by mouth daily.”