The average family physician sees about 25 patients per day,1 and many physicians still complete dictation for those visits at the end of the day. While it is usually easy to remember the clinical details of patient visits (with the help of a few notes), it is sometimes difficult to remember the prescriptions that were given, particularly when the patient received refills for problems unrelated to the visit.
One simple solution to this problem is to use a prescription “pad” that provides a copy of the prescription. Our practice has done just that, incorporating a prescription form into our charge ticket, which provides duplicates. The upper third of the ticket resembles a traditional superbill with check-off boxes for visit codes, lab tests, procedures, injections and immunizations. The middle third contains demographic and insurance information. (To accommodate our printer, we placed it in the middle rather than at the top.) And the lower third contains two perforated prescription forms.
At the end of each visit, the physician simply enters the reason-for-visit diagnosis in the diagnosis box, fills out the prescription form (or forms, if needed), tears it off and gives the patient his or her copy. The rest of the charge ticket, including our copy of the prescription, is placed on a clipboard and given to the patient to return to the checkout desk, where our cashier collects amounts owed. The clipboard helps the patient remember to take the form to the desk and not just put it in a pocket or purse.
There are several advantages to handling prescriptions in this way. First, we have more accurate and complete prescription data because we aren’t relying on anyone’s memory. Instead, we have an immediate paper record of the prescription. Second, we save time because we only have to write the prescription information once (on the prescription form) and we do not need to dictate it (the transcriptionist can gather it firsthand from our copy). Third, it is easier for our nurses to check on the prescriptions if the pharmacy calls with questions or if patients lose their prescriptions.
Admittedly, our system is simplistic, but that’s the beauty of it. Complex problems do not necessarily require complex solutions. Some day, we may see the implementation of a fully functioning electronic medical record system that tracks patients’ prescriptions and sends them electronically to the pharmacist. But for now, our duplicate prescription form does the job easily and inexpensively.
A CHARGE TICKET THAT DOUBLES AS A PRESCRIPTION PAD
The author and his colleagues have incorporated their prescription pad into their charge ticket, which provides duplicates. This simple change in process ensures that the practice has correct data about patients’ prescriptions and makes the information easier to record and locate.