Best practice in Repeat Prescribing – a Brief Guide for Medisec Members
Repeat prescribing is a common activity in general practice and typically involves all members of the practice team at various stages. It is also a common source of medico-legal complaint. It is now considered best practice that all practices have a formal policy on repeat prescribing and this should be communicated by the GP Principal or his / her named deputy, to all members of the practice team who are involved in repeat prescribing, including locums. Information on the policy should also be made available to patients of the practice and other key stakeholders, when requested. While we recognise that such policies can be complex, especially in practices with larger teams and more sophisticated ways in which patients can interact with the practice, this brief guide is intended as an introduction to the issues which Medisec members might consider in the development and implementation of a ‘Practice Policy on Repeat Prescribing’.
1. Authorisation of repeat prescriptions
- Authorising or reauthorizing a repeat prescription should, ideally, be undertaken face-to-face by a doctor who is familiar with the patient.
- At this consultation, the prescribing doctor should discuss with the patient that an ongoing prescription for the medicine is necessary, and ensure that the medicine is tolerated, not contraindicated and does not interact with other medicines.
- Based on issues such as age, cognitive function, polypharmacy, multi-morbidity, compliance, medical problems that arise, etc, the doctor should determine the frequency with which the patient should be reviewed.
2. Management of repeat prescription requests
Requests for repeat prescriptions should be made by the patient or his / her carer / representative While we recognise that such requests are most typically made by telephone, many mechanisms of communication are received. Irrespective of the mode of communication, we recommend that the practice receive adequate information to minimise prescribing errors (see Table 1).
Table 1. Information required by practice when managing requests for repeat prescriptions
- Name, address, date of birth of patient
- Medicines requested with as much detail as possible
- Number of months prescription requested
Upon receipt of a request, the patient or his / her representative should be advised that it will take at least two working days to process requests for a repeat prescription. All relevant information should be available by word of mouth, practice leaflet, repeat prescribing leaflet or practice website.
While we recognise that non-medical members of the practice team may generate a repeat prescription, as the GP principal is responsible for any issues arising from the prescription itself, we recommend that s/he ensure all staff involved in the repeat prescribing process are adequately trained in this regard.
While the prescription is being generated, a number of checks should be carried out, which might include:
- Is the medication list an accurate reflection of the medicines which have been authorised by the practice for repeat prescribing? If not, then the GP should be satisfied that the additional medicines should be prescribed (by review of past medical history and / or by telephone or face to face consultation). If the medication has not previously been prescribed, then a face to face consultation is recommended. – Is there evidence of non-adherence?
- Has the patient’s medical history changed so that medication side effects / contraindications may be a problem?
- Have interventions from secondary care or other health care professionals altered medication needs?
When writing / printing and signing a prescription, the doctor should ensure that the prescription is legible, dated, signed and includes the IMC registration number.
4. Approval / signing of repeat prescriptions
Prior to signing, the GP should also carry out a number of checks, which include:
- Is there evidence of any prescribing errors?
- Are any interactions, contraindications, etc?
- Is there a need for patient to attend for review because of the medication prescribed, or because of any new information which may have arisen since his / her last review / prescription request?
- Should the prescription be hand-written, e.g. in the case of controlled drugs?
5. The medication / medical review
All patients receiving long term medicines through the repeat prescribing system need to be reviewed regularly. The interval should be determined by the GP / practice and will vary on a case by case basis. The review can involve either
- review of the patient’s records to check medication and / or medical history, or
- review in a face to face consultation.
This review might involve:
- The medical problems for which medications are being prescribed?
- Medication dose, frequency, efficacy, tolerability, interactions, contraindications?
- Any investigations needed?
- Change in patient’s clinical status
- Patient ideas, concerns?
6. Quality assurance – critical incident review and clinical audit
The practice policy on repeat prescribing should include a method for incident reporting and recording and be subject to regular audit and quality review.
7. Common medico-legal problems arising from repeat prescribing
Such problems account for 18% of requests for advice / assistance which Medisec receives and these are detailed in Table 2.
Table 2. Repeat prescribing related issues commonly reported by Medisec members.
- Deficits in prescribing practices
- Failure to properly monitor medication dosage
- Medication reconciliation especially with hospital/community/consultant interface
- Proper monitoring of patient and issuing repeat prescription
- Secretarial transcriptions and errors due to computer drop down menus
- Mis-prescribing or over prescribing of benzodiazepines
- Methadone prescribing in the absence of adequate training.
8. Further reading
- Bradley, C & ICGP Quality in Practice Committee. Repeat Prescribing Quick Reference Guide. 2013. (Available from www.icgp.ie/QIPRepeatPrescribing)
- Prescribing in General Practice. RCGP Online Elearning module. Available from: https://elearning.rcgp.org.uk/course/view.php?id=136.