E-Prescription System

EPRESCRIPTION.md

E-Prescription System

Complete guide to creating, managing, and dispensing electronic prescriptions in MyClinicSoft.

Overview

The E-Prescription system provides digital prescription management with:

  • Electronic prescription creation
  • Drug interaction checking
  • Allergy warnings
  • Formulary integration
  • Digital signatures
  • Prescription printing
  • Dispensing tracking
  • Refill management

Accessing Prescriptions

Navigate to Prescriptions from the main menu.

View Options:

  • All prescriptions
  • Active prescriptions
  • Completed prescriptions
  • Pending dispensing
  • By patient
  • By doctor
  • By date range

Creating a Prescription

From Clinical Visit

During Patient Visit:

  1. While documenting visit, click Create Prescription
  2. Patient and doctor pre-filled
  3. Prescription form opens
  4. Add medications
  5. Save and link to visit

Direct Prescription Creation

  1. Go to Prescriptions → New Prescription
  2. Fill in prescription details

Prescription Form

Patient Information

Auto-filled:

  • Patient name
  • Patient ID
  • Age
  • Weight (for dosing calculations)
  • Known allergies (displayed prominently)

Allergy Warning: If patient has known drug allergies, prominent warning displayed:

⚠️ ALLERGY ALERT
Patient allergic to: Penicillin, Sulfa drugs
Reaction: Rash, swelling

Doctor Information

Auto-filled:

  • Prescribing doctor name
  • License number
  • Specialty
  • Digital signature

Prescription Details

Date:

  • Date written (defaults to today)
  • Valid until (typically 1 year)

Diagnosis:

  • Linked from visit (if applicable)
  • Or manually enter
  • ICD-10 code recommended

Adding Medications

Search for Medication

  1. Click Add Medication
  2. Search by:
    • Generic name (e.g., "Amoxicillin")
    • Brand name (e.g., "Amoxil")
    • Indication (e.g., "antibiotic")
  3. Select from results

Search Results Show:

  • Generic name
  • Brand name(s)
  • Strength available
  • Form (tablet, capsule, syrup)
  • Stock level (if in inventory)

Medication Details

For each medication, specify:

Basic Information

  • Medication Name* (required)

    • Auto-filled from selection
    • Example: Amoxicillin 500mg capsule

  • Quantity* (required)

    • Number to dispense
    • Example: 21 capsules
    • System checks stock availability

Dosing Instructions

  • Dosage* (required)

    • How much to take
    • Example: 1 capsule, 2 tablets, 5 mL

  • Frequency* (required)

    • How often
    • Dropdown options:
      • Once daily (QD)
      • Twice daily (BID)
      • Three times daily (TID)
      • Four times daily (QID)
      • Every 4 hours
      • Every 6 hours
      • Every 8 hours
      • Every 12 hours
      • As needed (PRN)
      • Custom

  • Duration* (required)

    • How long
    • Examples:
      • 7 days
      • 2 weeks
      • 1 month
      • Until finished
      • Ongoing

  • Route

    • Oral (PO) - default
    • Sublingual (SL)
    • Topical
    • Inhalation
    • Injection (IM, IV, SC)
    • Rectal
    • Ophthalmic
    • Otic

Special Instructions

  • Instructions (detailed directions)

    • Examples:
      • "Take with food"
      • "Take on empty stomach"
      • "Take before bedtime"
      • "Dissolve in water"
      • "Do not crush or chew"
      • "Complete full course even if feeling better"

  • Purpose (patient education)

    • Examples:
      • "For infection"
      • "For pain relief"
      • "For blood pressure"
      • "To prevent complications"

Example Medication Entry

Medication: Amoxicillin 500mg capsule
Quantity: 21 capsules
Dosage: 1 capsule
Frequency: Three times daily (TID)
Duration: 7 days
Route: Oral
Instructions: Take with food. Complete full course.
Purpose: For bacterial infection

Patient Sees (Plain Language):

Amoxicillin 500mg capsule
Take 1 capsule by mouth three times daily for 7 days
Take with food
Complete the full course even if you feel better
This medication is for your bacterial infection

Drug Interaction Checking

Automatic Checking

System automatically checks for interactions:

Checks Against:

  • Other medications in current prescription
  • Patient's active prescriptions
  • Patient's regular medications (in medical history)

Interaction Types:

  • 🔴 Severe - Do not use together
  • 🟠 Moderate - Use with caution
  • 🟡 Minor - Monitor patient

Interaction Alert:

⚠️ DRUG INTERACTION WARNING

Interaction: Warfarin + Amoxicillin
Severity: Moderate
Effect: Increased bleeding risk
Recommendation: Monitor INR closely. Consider dose adjustment.

Continue anyway? [Yes] [No] [View Details]

Doctor Actions:

  • Review interaction details
  • Consult reference materials
  • Modify prescription if needed
  • Document reason if proceeding
  • Add monitoring instructions

Allergy Checking

System checks medications against patient allergies:

Allergy Alert:

🚨 ALLERGY ALERT

Patient is allergic to: Penicillin
You are prescribing: Amoxicillin (Penicillin family)
Known reaction: Rash, difficulty breathing

This medication should NOT be prescribed!

[Change Medication] [Document Override]

Override:

  • Requires documentation
  • Reason must be compelling
  • Additional monitoring required
  • Patient counseling documented

Multi-Drug Prescriptions

Adding Multiple Medications

  1. Add first medication (complete all details)
  2. Click Add Another Medication
  3. Add second medication
  4. System checks interactions
  5. Continue adding as needed

Common Multi-Drug Scenarios:

Example 1: Antibiotic + Pain Relief

1. Amoxicillin 500mg - for infection
2. Ibuprofen 400mg - for pain/inflammation
3. Vitamin B-complex - to prevent side effects

Example 2: Hypertension Treatment

1. Losartan 50mg - morning
2. Amlodipine 5mg - evening
3. Aspirin 81mg - morning (cardioprotection)

Example 3: Diabetes Management

1. Metformin 500mg - twice daily
2. Glimepiride 2mg - morning
3. Vitamins for diabetics - daily

Prescription Summary

Shows all medications in one view:

  • Quick review before finalizing
  • Check for duplicates
  • Verify dosages
  • Confirm durations
  • Total cost estimate

Additional Instructions

General Instructions

Add instructions for entire prescription:

  • When to take medications
  • Storage instructions
  • What to avoid
  • When to follow up
  • Emergency instructions

Example:

GENERAL INSTRUCTIONS:
- Take all medications as directed
- Store in cool, dry place
- Avoid alcohol while taking antibiotics
- Return for follow-up in 1 week
- Call immediately if symptoms worsen or new symptoms develop
- Complete antibiotic course even if feeling better

Pharmacy Instructions

Special instructions for pharmacist:

  • Dispensing notes
  • Substitution allowed/not allowed
  • Special preparation
  • Patient counseling points

Prescription Validation

Before saving, system validates:

Required Fields:

  • ✅ Patient selected
  • ✅ Doctor identified
  • ✅ At least one medication
  • ✅ All dosages specified
  • ✅ All frequencies specified
  • ✅ All durations specified

Safety Checks:

  • ✅ No severe drug interactions (or documented)
  • ✅ No allergy conflicts (or documented)
  • ✅ Dosages within safe range
  • ✅ Durations appropriate
  • ✅ Stock available (if dispensing)

Warnings:

  • ⚠️ Unusually high dose
  • ⚠️ Unusually long duration
  • ⚠️ Duplicate medication
  • ⚠️ Age-inappropriate medication

Saving and Signing

Digital Signature

  1. Review complete prescription
  2. Click Sign Prescription
  3. Enter password or use digital signature device
  4. Prescription digitally signed

Digital Signature Includes:

  • Doctor's name and license number
  • Date and time of signing
  • Secure hash of prescription
  • Cannot be altered after signing

Saving Options

  • Save Draft - Save without signing (can edit later)
  • Save and Sign - Finalize prescription
  • Save and Print - Print immediately after saving
  • Save and Dispense - Go directly to dispensing

Printing Prescriptions

Prescription Format

Professional prescription with:

[Clinic Logo and Letterhead]

PRESCRIPTION
Rx No: RX-2024-00567
Date: January 15, 2024

Patient: Maria Santos                    Age: 39 years
Patient ID: PT-2024-00123               Weight: 58 kg

Known Allergies: None

Diagnosis: Acute Upper Respiratory Tract Infection (J06.9)

------------------------------------------------

Rx

1. Amoxicillin 500mg capsule
   Disp: 21 capsules
   Sig: Take 1 capsule by mouth three times daily for 7 days
        Take with food. Complete full course.

2. Cetirizine 10mg tablet
   Disp: 7 tablets
   Sig: Take 1 tablet by mouth once daily for 7 days
        Take before bedtime.

3. Vitamin C 500mg tablet
   Disp: 30 tablets
   Sig: Take 1 tablet by mouth once daily for 30 days

------------------------------------------------

INSTRUCTIONS:
- Take all medications as directed
- Drink plenty of fluids
- Get adequate rest
- Return if no improvement in 3 days
- Call immediately if difficulty breathing

Generic substitution: ☐ Allowed  ☑ Not Allowed

------------------------------------------------

Dr. Juan Dela Cruz, MD
License No: 1234567
[Digital Signature]

Valid for: 1 year from date issued
This is an electronic prescription

[QR Code for verification]

[Clinic Contact Information]

Printing Options

  • Original - For patient/pharmacy
  • Copy - For patient records
  • Duplicate - If lost (marked as duplicate)

Print Settings:

  • Print on letterhead
  • Include clinic logo
  • Include QR code for verification
  • Watermark for copies

Prescription Dispensing

Recording Dispensing

When medication given to patient:

  1. Open prescription
  2. Click Mark as Dispensed
  3. Record details:
    • Date dispensed
    • Quantity actually dispensed
    • Batch number (for tracking)
    • Expiration date
    • Dispensed by (staff member)
    • Patient signature (optional)

System Actions:

  • Updates prescription status to "Dispensed"
  • Deducts from inventory
  • Links to inventory transaction
  • Records in patient medication history
  • Generates dispensing label (optional)

Partial Dispensing

If full quantity not available:

  1. Click Partially Dispense
  2. Enter quantity dispensed
  3. System tracks remaining quantity
  4. Patient can return for balance

Example:

Prescribed: 30 tablets
Dispensed: 15 tablets (stock low)
Remaining: 15 tablets (to dispense later)
Status: Partially Dispensed

Dispensing Label

Optional label for medication packaging:

[Clinic Name]

Maria Santos
Take 1 capsule three times daily for 7 days
Take with food

Amoxicillin 500mg capsule
Qty: 21
Dispensed: Jan 15, 2024
Expires: Dec 2025
Batch: BA12345

☎ Call clinic with questions

Prescription Refills

Requesting Refill

Patient Requests Refill:

  • Via phone call
  • Via patient portal
  • In person

Staff Process:

  1. Search for patient
  2. View medication history
  3. Find original prescription
  4. Click Refill Prescription
  5. System creates new prescription
  6. Pre-filled with same medications
  7. Review and update if needed
  8. Doctor approval (if required)

Refill Rules:

  • Non-controlled substances: Can refill
  • Controlled substances: New prescription required
  • Expired prescriptions: New consultation needed
  • Maximum refills: Per clinic policy

Refill Approval

If prescription requires doctor approval:

  1. Refill request created
  2. Doctor notified
  3. Doctor reviews:
    • Original prescription
    • Patient's recent visits
    • Current condition
    • Lab results (if applicable)
  4. Doctor approves or denies
  5. If approved, prescription activated
  6. Patient notified

Prescription Reminders

Refill Reminders:

  • Sent before medication runs out
  • Based on: Quantity ÷ Daily dose = Days supply
  • Reminder sent: 7 days before running out

Example:

Hi Maria, your Amoxicillin prescription will run out in 7 days.
If you need more, please contact us to schedule follow-up.
- YourClinic

Managing Prescriptions

Viewing Prescription History

Patient Level:

  1. Go to patient record
  2. Medications tab
  3. See all prescriptions:
    • Current/active
    • Completed
    • Cancelled
    • Historical

System Level:

  1. Go to Prescriptions
  2. Search and filter:
    • By patient
    • By doctor
    • By medication
    • By date range
    • By status

Editing Prescriptions

Before Dispensing:

  • Can edit freely
  • Update medications
  • Change dosages
  • Add instructions
  • Re-sign after changes

After Dispensing:

  • Cannot edit
  • Must create new prescription
  • Or add addendum note

Cancelling Prescriptions

If prescription no longer needed:

  1. Open prescription
  2. Click Cancel Prescription
  3. Enter reason:
    • Patient declined
    • Error in prescription
    • Changed treatment plan
    • Patient allergic
    • Other
  4. Confirm cancellation

System Actions:

  • Status: Cancelled
  • If already dispensed, no stock reversal
  • Documented in patient record
  • Doctor notified

Prescription Reports

Available Reports

Navigate to Reports → Prescriptions

Reports:

  • Prescriptions by doctor
  • Prescriptions by medication
  • Most prescribed medications
  • Prescription patterns
  • Controlled substance log
  • Dispensing report
  • Refill report
  • Prescription costs

Analysis:

  • Prescribing trends
  • Medication costs
  • Generic vs. brand usage
  • Controlled substance tracking
  • Compliance with formulary

Controlled Substances

Special Handling

For controlled medications (narcotics, etc.):

Additional Requirements:

  • Special prescription form
  • Cannot be refilled (new Rx each time)
  • Dual authorization (if required)
  • Special logging
  • Regulatory reporting

Controlled Substance Prescription:

⚠️ CONTROLLED SUBSTANCE
SCHEDULE II - OPIOID

[Red border on prescription]
[Additional security features]
[Stricter signature requirements]

Tracking:

  • Every prescription logged
  • Every dispensing recorded
  • Regular inventory reconciliation
  • Reports to authorities
  • Audit trail maintained

Patient Medication List

Current Medications

Patient's complete medication list:

  • All active prescriptions
  • Over-the-counter medications
  • Supplements and vitamins
  • External medications (from other doctors)

Use for:

  • Drug interaction checking
  • Medication reconciliation
  • Discharge planning
  • Referrals to specialists

Medication History

Complete medication history:

  • All medications ever prescribed
  • When prescribed
  • By which doctor
  • For what condition
  • Duration taken
  • Effectiveness notes

Clinical Value:

  • Track treatment history
  • Identify effective medications
  • Avoid failed treatments
  • Monitor adherence patterns

Tips for Safe Prescribing

  1. Verify Patient - Confirm correct patient
  2. Check Allergies - Always review allergies first
  3. Review Current Meds - Check what patient already taking
  4. Use Generic Names - Clearer, avoid brand confusion
  5. Be Specific - Clear dosing instructions
  6. Check Interactions - Don't override without good reason
  7. Document Thoroughly - Detailed instructions help compliance
  8. Consider Cost - Prescribe affordable options when possible
  9. Follow Up - Schedule review for chronic medications
  10. Educate Patient - Explain purpose and proper use

Common Issues

Patient Cannot Afford Medication

Solutions:

  • Prescribe generic alternative
  • Reduce quantity (starter pack)
  • Split prescription (dispense gradually)
  • Patient assistance programs
  • Alternative medication
  • Free samples (if available)

Medication Out of Stock

Solutions:

  • Prescribe alternative medication
  • Reduce quantity temporarily
  • Refer to external pharmacy
  • Order for next visit
  • Emergency supply from another source

Patient Confused About Instructions

Solutions:

  • Use plain language
  • Write clearly on prescription
  • Verbal counseling
  • Demonstration if needed
  • Written patient education materials
  • Follow-up call

Best Practices

  1. Always Check Allergies - Before prescribing anything
  2. Use Standard Abbreviations - Avoid confusion
  3. Include Purpose - Helps patient understand and remember
  4. Simple Regimens - Once or twice daily better than complex
  5. Appropriate Duration - Not too short, not too long
  6. Patient Education - Explain how and why
  7. Follow Up - Schedule review for chronic medications
  8. Document Everything - Include rationale for choices
  9. Consider Compliance - Prescribe what patient can actually do
  10. Safety First - When in doubt, consult references

Related Documentation