Tuesday 6 February, 2007

How to write a PBS prescription

Posted in Emergency Dept., General Practice, Medicine, Michael Tam, Resources, Wards at 23:05 by Michael Tam

Original article by: Michael Tam :: Printer friendly

Resources

Application for approval to prescribe medications under the Pharmaceutical Benefits Scheme (by a registered medical practitioner)

The is the Medicare Australia application form for a prescriber number [118 Kb]

Writing an R/PBS (repatriation/pharmaceutical benefits scheme) presciption (aka “external” script for hospital based JMOs) is easy and simple when you know how. Incredibly (looking retrospectively), I don’t think that anyone actually went through with me how to write one. I’m sure there were more than a handful of community pharmacists shaking their heads (or their fists) at my dodgey scripts when I was a resident in ED!

This article is aimed mostly at interns and residents on how to write a community R/PBS prescription.

Who can write a PBS or RPBS script?

You must have a prescriber number and general (i.e., unconditional) registration with the state medical board. Interns (PGY1) have neither so they cannot legally write an R/PBS script. Once you’ve satisfactory completed your internship and have obtained general registration, then you can apply to Medicare Australia for a prescriber number. Your training hospital may not necessarily request that you do this since you only need a provider number to function within the public hospital system. The appropriate form can be downloaded at the top of this article.

Change your mindset

The thing to realise is that PBS scripts are very different beasts to an internal hospital medical chart. They are designed for a different purpose. Hospital medication charts are designed for rapidly changing medications / dosages while PBS scripts are for long term dispensing. You must change your way of thinking for a PBS script.

Box sizes

Once a hospital medication chart is filled, any one medication can be continued “ad infinitum” if so needed, though perhaps more realistically, for the exact clinically indicated period. Medications are dispensed on a daily basis.

With PBS scripts, you must consider the total number of tablets/doses as well as box sizes and repeats.

For example, if you want to discharge someone on cephalexin 500 mg, four times a day for a week, simply writing this on a script is not satisfactory. A box of cephalexin comes with 20 capsules; only enough for 5 days. In this case, you must write a script for a box with one repeat.

PBS indications

PBS indications are not the same as RPBS indications and neither are necessarily the same as clinical indications. PBS indications are the conditions that the government (through the PBS) will pay for the medication out of the public purse and are usually only a subset of all possible clinical indications. RPBS indications are usually somewhat more generous (benefits to war veterans and their family). Prescribing through the RPBS is usually cheaper for the patients as well.

Some common examples:

  • celecoxib (and all the COX-2 inhibitors) is only PBS subsidised for symptomatic treatment of osteoarthritis or rheumatoid arthritis (i.e., the government won’t pay for it being used for muscular pain).
  • gabapentin only has a PBS indication for treatment of epilepsy. Unless the patient has access the the RPBS, then the government won’t subsidise it for use in neuropathic pain.
  • rosiglitazone (and all the glitazones) is not PBS subsided for monotherapy.
  • olanzapine (and most of the atypical antipsychotics) is only PBS subsided for treatment of schizophrenia maintenance of bipolar affective disorder (Type I).

Some limitations

  • You can only write three medications per single script.
  • R/PBS medications that require authority must be written on a specific PBS/RPBS authority prescription pad (not covered in this article).
  • Schedule (S8) medications (e.g., morphine) must be written individually on their own script (must include words and numbers for the strength and quantity; see below examples).
  • Schedule 100 (S100) medications (e.g., etanercept) cannot be written by you (if it is an S100 drug you will know if you can prescribe it as specific training is required).
  • Non-PBS items should not be written on the same script with PBS items.

Example of a standard PBS script

  1. Contact details at the top;
  2. personal prescriber number (where “1234567″ is on the above sample);
  3. patient’s name and address;
  4. tick either PBS or RPBS boxes;
  5. tick the “Brand substitution box not permitted” box if necessary;
  6. drug name (generic name preferable) and strength;
  7. dosing amount and frequency;
  8. quantity of the medication and number of repeats (if applicable);
  9. signature and date.

Example of an S8 script

  1. Basically the same as the standard script;
  2. only one item only per script;
  3. medication strength (i.e., 5 mg) and total quantity (i.e., 20 tablets) must be in both words and numbers.

Example of a private script

  1. It isn’t actually necessary to write a private script on PBS stationary but most people do;
  2. The script must have your name and prescriber number;
  3. the patient’s name and address;
  4. cross out both the PBS and RPBS boxes and note that it is a “private script”;
  5. drug name, dose, frequency and quantity;
  6. signature and date.

Tips and Hints

  1. Give both copies of the prescription to the patient (one copy is for the pharmacist, the other for Medical Australia/Department of Veteran Affairs).
  2. Beware of the irritating box sizes that don’t make sense. A good example is with clindamycin. The antibiotic guidelines(1) suggest clindamycin 450 mg, three times a day for 7-10 days for mild early cellulitis and erysipelas (in immediate penicillin hypersensitivity). As clindamycin comes in 150 mg capsules, that means 9 capsules a day. A box of 25 capsules then lasts less than 3 days! Furthermore, under the PBS, it doesn’t allow for repeats. If you send someone home from the emergency department with a script for clindamycin the result would be an annoyed patient, an annoyed general practitioner or the patient taking only a fraction of the recommended course. Please ensure there are alternative arrangements in place first!

References

(1) Cellulitis and erysipelas. Therapeutic Guidelines, Antibiotic version 13. October 2006.

About these ads

17 Comments »

  1. Jimmy said,

    Hi,

    Firstly, I want to say that this is an excellent blog, even though I am a pharmacy student, I find it extremely enlightening.

    In regards to NHS prescriptions, you’ve summarised the process very well. In addition to Tips & Hints 2., working in community pharmacy, a pet hate is the use of MQ and MQMR, maximum (NHS) quantity and maximum (NHS) quantity maximum (NHS) repeats respectively.

    It is preferable to leave it blank, where the pharmacist will supply the smallest quantity feasible*, and recommend the patient see the GP. Medicare Australia is not very appreciative of MQMR scripts.

    * This is usually one box/bottle, e.g. simvastatin will be supplied in a box of 30 tablets. If a doxycycline (100mg) script is written, as there are pack sizes of 7, 21 and 28 available, Medicare Aust will only subsidise for 7 tablets if MQ is specified.

  2. Michael Tam said,

    Thanks for you comments Jimmy!

    I myself have been guilty of using the “max quantities, max repeats” line on occasion (usually when the computer isn’t working and I can’t find a copy of Mims).

  3. oma acevedo said,

    i want to thank you for such a detailed description of how to understand writing a prescription. i got much out of it. im a medical assistant and at times i was called to write it down for a doctor’s approval. one thing however, when i was working the doctors use abbreviations on their instructons (ex: B.I.D=twice a day, PRN=whenever neccesary) i didnt see an example using any abbreviations. if possible for later updates of this site there can be some to view.

  4. Brayden Dyar said,

    Hi, i’m doing my internship at RBH and i’v been in trouble several times now for writing incorrect abbreviations on my prescriptions (mostly drugs in the schedual 8 range) though two comlaints have also come from sripts requiring authority including an anti biotic “Roxin”. Can you make these examples more precise as i have found this sit5e to be useful.

  5. Michael Tam said,

    With regards to abbreviations, avoid them where possible, unless they are obvious.

    The following abbreviations are usually acceptable:
    bd = twice a day
    tds = three times a day
    qid = four times a day
    PRN = as needed
    g = gram
    mg = milligram
    mcg = microgram

    The following are generally unacceptable (as they can be ambiguous or misread):
    ANY abbreviation for a medication name (e.g., MTX for methotrexate)
    ug = microgram (the Greek “mu” can often be misread as “m”)
    d or D = daily
    U = units

    My recommendation is to prescribe generically (i.e., norfloxacin rather than “Roxin”) unless the use of the generic can cause confusion or in the setting of combination drugs.

    As for S8 drugs, see my example of the script for oxycodone. You need to write both numbers and letters for the strength of the medication and the quantity prescribed. Furthermore, you are only allowed one medication per script.

    In terms of authority scripts, this is beyond the scope of this article. In any case, you need to have a PBS/RPBS authority script pad to write authority scripts, something that most hospital doctors would NOT have, and something that most Emergency Departments do not have. Assuming that you actually have the script pad, then the other information you need is the patient’s Medicare card number, the authority script number (on the script) and your prescriber number. Then, you need to ask for the medication, the quantity and repeats and then give the reason for the authority (see MIMS, for many drugs the approved authorities are quite proscriptive). The Medicare officer will then check the history and give you the authority code to write on the script.

    The authority script is in triplicate: you give the patient the top two copies and you are meant to keep the third.

    Regards.

  6. Hildy said,

    why do you need a prescriber number for a private script?

  7. Michael Tam said,

    A private script of a non-OTC medication (or an S4/8 quantity) still needs to be written by a medical professional, thus name, contact details, prescriber number and signature.

  8. Reis said,

    Is a personal prescriber number valid Australia-wide? I’m moving interstate shortly having completed my internship and I’m not sure whether I need to apply for another one…

    cheers.

  9. Michael Tam said,

    Correct me if I’m wrong, but I didn’t think that you were entitled to a prescriber number until after general registration (i.e., after internship).

    Ignoring that point, once you have a prescriber number then yes, I believe that it follows you. You will need to apply for a provider number in every new facility (i.e., hospitals) though.

    Cheers.

  10. Reis said,

    Thanks for the advice.

    yeah, so I heard. WA must be weird…because we all get allocated prescriber numbers in our intern year.

  11. Whitey said,

    Yes, one prescriber number is definitely enough and will work in any state – you will keep this number for ever. Provider number, as stated above, is quite different and I think people sometimes get the two confused because they sound similar! Prescriber number should be seven digits, no letters.

    I’m sure I got mine as a PGY2, but maybe WA is different as you say.

  12. Ramesh said,

    I just came across this now. Again I must say it is a fantastic summary. In regards to a prescriber number, depending on which state legislation you are following, a prescriber number is not necessary for a valid script. However it is a requirement for dispensing under the NHS/PBS.

  13. Fong said,

    Hi there! Just wanted to say what a fantastic resource this is! As a pharmacist, I am always calling doctors about their scripts and it’s great to be able to refer them to this! Thanks heaps!

  14. Dr Brayden Dyar said,

    Hi, its brayden again. Thanks so much for the advice you gave me about abreviations. iv now finished my internship at the RBWH but am now working as the MO at Arther Gorrie Correcional Centre. I have so many inmates coming off illict drugs but more so off buprenorphine/methadone. i am useing diazepam, and clonidine to help the withdrawal symptoms. Is there any other options in this case? (bare in mind any opiate drugs are not permitted in AGCC)

  15. Sam said,

    Hi Michael,
    Can the prescriber use their home address for their contact details PBS or private prescriptions?

  16. Sam said,

    Can anyone tell me if the prescriber can use their home address for their contact details for PBS or private prescriptions?

  17. Anny said,

    for s8 scripts, does it need to be in the doctor’s handwriting? so computerised scripts aren’t legal?


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 55 other followers

%d bloggers like this: