repeat prescriptions

Re: repeat prescriptions

Anthony Todd — Thu, 20 May 2010 08:45:19 GMT

[quote user="Utlendigur"]I certainly wouldn't be confident about going back to allowing receptionists to simply dispense repeats as I don't think they are going to ask questions (they seemed to see it simply as a transaction), ask the right questions, understand the significance of what the client says or know when to ask for advice.[/quote]

Hooray, this and the rest of the post says all I wanted to say but better! But why are we in a minority??

I had the same, surprising, results when I checked repeats, some even had "as before" as the directions" and written by a vet.......

Re: repeat prescriptions

Vikki Halliday LLB — Wed, 19 May 2010 19:38:29 GMT

I have worked in practices with similar systems, e.g. whiteboards, diaries and notebooks. I would agree that every thing needs to be signed off by a vet, and would never allow a receptionist to give a repeat prescription without this safety net.

The only thing they are allowed to dispense without checking are GSL equivalent wormers.

However the first post seemed to me to be more a question of how often vets need to see animals before prescribing repeats. And the fact that there is a clear policy that lay staff are aware of makes itmuch easier for them to keep clients informed at the first phonecall, especially if a vet is not available to explain why Fluffy needs to be seen as his last check up for his Felimazole was 11 months and 3 days ago........

Re: repeat prescriptions

Utlendigur — Wed, 19 May 2010 17:29:36 GMT

We used to have a policy of putting a note in the records to say the owner can have rpts for X months/times or R/v 6mnths or some other instruction. The problem we found was a minority of the staff simply don't read the notes, miss the instructions, especially if it is busy and the pet has reams of notes, think they know better, or get persuaded by a difficult owner. I spent a few hours one weekend pulling up records of common drugs we dispensed (rimadyl, felimazole, fruse etc) and found numerous cases where the system had broken down and staff had simply continued to dispense the drugs without asking a vet - in some cases in direct contradiction to vet's instructions. We now have a system where whoever takes the call prints off a request, adds any notes from client eg "on holiday next week can they defer check 1mnth" or "seems much better on tx". The vet dealing with the case reviews the case, signs the form and adds any instructions to pass on to the client - or the client is called to tell them the case needs seeing. Staff know that most drugs have 6mnths checks and can warn owners if they think a r/v may be needed but we don't set it in concrete and the decision is the vet's depending on the animal's condition, the drug, the owner etc. It gives some flexibility but stops cases dropping of the radar. I certainly wouldn't be confident about going back to allowing receptionists to simply dispense repeats as I don't think they are going to ask questions (they seemed to see it simply as a transaction), ask the right questions, understand the significance of what the client says or know when to ask for advice.

Re: repeat prescriptions

Clive Ansell — Wed, 19 May 2010 09:35:46 GMT

[quote user="Anthony Todd"]

[quote user="Gillian Mostyn"]All repeats referred immediately to a vet?[/quote]

Do the vets know how many requests are greeted with "No, it's x months and one day".

Then they have a really pissed off client that they will be unlikely to see again, ever, and an untreated animal.

Or a polydipsic diabetic on the same inadequate insulin dose because the repeat was within the arbitrary x months.

[/quote]

Again, common sense needs to prevail.

If it were X months + 1 day, and the are no concerns about the patient and an OK client, I would probably say "fine, but needs to make check appt in the next week or so". What should happen where reception and nursing staff are up to speed is; at (X - 1) months, or when the last meds were collected, it should have been said "OK this time, but will need a check next time at X months"

Where someone phones for repeat insulin, they should always be asked how is he/she? are drinking, eating, peeing, weight all OK? If not then a vet needs to assess the case. If they have become polydipsic, then of course they need to be seen. I like to see diabetics every 3 months at least.

Re: repeat prescriptions

Anthony Todd — Wed, 19 May 2010 08:55:32 GMT

[quote user="Gillian Mostyn"]All repeats referred immediately to a vet?[/quote]

Well, perhaps "immediately" is a bit strong, should have left it out, but as most referrals would be a "Yeah, fine" which doesn't take that long I can't think it'll add too much to your day.

It's better vet.med., the client the vet and the animal are happy and the vet knows the repeat is correct, the animal is fine on the current script and sort of technically "under some care".

I wonder just how many repeat scripts a very busy practice processes in a day? Perhaps someone can tell me.

Do the vets know how many requests are greeted with "No, it's x months and one day".

Then they have a really pissed off client that they will be unlikely to see again, ever, and an untreated animal.

Or a polydipsic diabetic on the same inadequate insulin dose because the repeat was within the arbitrary x months.

Re: repeat prescriptions

Gillian Mostyn — Wed, 19 May 2010 08:11:56 GMT

[quote user="Anthony Todd"]Best to refer all repeats to a vet, someone will be on their mobile![/quote]

Are you serious? All repeats referred immediately to a vet? It would have to be a very quiet practice to make that possible!

Re: repeat prescriptions

Anthony Todd — Tue, 18 May 2010 23:38:01 GMT

[quote user="Clive Ansell"]If they are unsure, they should not dispense without first speaking to a vet. [/quote]

Again a good common-sense policy, avoiding the 12 months and one day denial, but hoping the receptionist asks pertinent questions regarding the animal.

Best to refer all repeats to a vet, someone will be on their mobile!

Is that such an onerous big-deal?

Re: repeat prescriptions

Anthony Todd — Tue, 18 May 2010 23:29:20 GMT

[quote user="Vikki Halliday"]Lay staff can dispense POM and POM-V products where:[/quote]

Whoops you're quite right but

[quote user="Vikki Halliday"]This can be in the form of a note on the clinical records e.g. can have repeats up to (delete as appropriate) 3/6/12 months.[/quote]

we're discussing the 3/6/12/month and 1 day scenario ie the imposition of a rigid policy.

and conversely " although the dog is still fitting but, as it's within the 3/6/12 month "policy" then just give the repeat.....

So refer to the vet, if the client has to wait 24 hours for the repeat then so be it; it may stop the dog's fits or save the owner trekking back with t he pet for a pointless "examination".

Re: repeat prescriptions

Evelyn Barbour-Hill — Tue, 18 May 2010 18:33:01 GMT

[quote user="Vikki Halliday"]PS: You haven't seen my Traffic Warden uniform have you?[/quote]

No but we'd love to. Would make a change from French Maids.

Re: repeat prescriptions

Vikki Halliday LLB — Tue, 18 May 2010 15:10:29 GMT

[quote user="Anthony Todd"]Only vets. can dispense POMs [/quote]

No NO NO!

Lay staff can dispense POM and POM-V products where:

The veterinary surgeon individually aurthorises each transcation before the product is supplied

and that they are satisfied that the person who hands it over is competent to do so.

This can be in the form of a note on the clinical records e.g. can have repeats up to (delete as appropriate) 3/6/12 months.

Interestingly the VMD guidance note states that " It is considered good practice for veterinary surgeons to have in place a practice Standard Operating Procedure if they intend to delegate supply of veterinary medicines under their responsibility."

So my woefully inadequate policy actually has a base in the current guidelines..

Re: repeat prescriptions

Clive Ansell — Tue, 18 May 2010 14:30:46 GMT

I always try to leave clear instructions for lay and nursing staff within the clinical notes; for example " can have repeats up until July", " OK for 6 months repeats", MUST BE SEEN, or "needs to be seen for check and T4 test before meds can be given". If they are unsure, they should not dispense without first speaking to a vet.

Re: repeat prescriptions

Anthony Todd — Tue, 18 May 2010 14:19:06 GMT

[quote user="Vikki Halliday"]No. Policies exist to guide the lay staff when you are not available. That way they are not put in a position where they are under pressure from clients to dispense medication where the animal requires to be seen.[/quote]

Oh dear, we're going round and round!

Only vets. can dispense POMs so how can a policy guide the lay staff unless they behave like Parking Enforcement Officers: 12 months and one day "NO You Can't!"

My last try; the policy should be: refer to the vet. who hopefully will use common medical sense, think of the animal first, do a risk benefit analysis and decide taking full responsibility for the decision.

There are enough examples in the thread already and very few grey areas.

Re: repeat prescriptions

Gillian Mostyn — Tue, 18 May 2010 12:15:50 GMT

[quote user="Louise Alexander"]Your post sounds like receptionists/whoever answers the phone dispenses medications?[/quote]

I thought that receptionists can dispense medications? As long as the vet has prescribed it - for example 'can pick up more meds as req'd with recheck in 3 months' - then the receptionist isn't breaking any law by carrying out those instructions? Am I wrong?

Re: repeat prescriptions

Clive Ansell — Tue, 18 May 2010 11:53:41 GMT

Working in OOH's clinics we constantly see the "1215 on a Saturday" syndrome. This is where a client has just discovered they don't have enough Phenobarbitone/Fortekor/Soloxine for the weekend and their practice closed 15 minutes ago.

I never know what to do with these, as the animal is not strictly "under our care" If I can see a labelled packet with practice name, drug, dose etc I will usually dispense enough until their regular practice opens. Other vets will insist on seeing the animal and charging an ooh consult. Again, no hard and fast rules, and common sense has to prevail.

Re: repeat prescriptions

Vikki Halliday LLB — Tue, 18 May 2010 11:29:53 GMT

[quote user="Louise Alexander"]

Speaking of requests, does anyone have those clients who either ring or call in and demand the medications straight away? But sods law there isn't a vet around so they will have to wait, or even worse, the animal hasn't been seen so they will need to come back with the animal? Then the client gets very cross at being made to wait! I always feel like reminding these people that pharmacies work by a '3 day wait' for repeat prescriptions...!!!

[/quote]

Yup, get them frequently, and also usually for the dogs that are on obscure enteric coated diltiazem or something else that we know takes more than 24hr to get hold of.

If you have a sign at reception that clearly states in large bold type that all repeat prescriptions require 24 hrs notice, then there can be no argument.

[quote user="Anthony Todd"] Is it too hard to refer each and every request to the vet for a decision[/quote]

Sometimes, yes. If there is not a vet on the premises, or you are in the middle of consults or something else which means you cannot be disturbed.

[quote user="Anthony Todd"]

Rigid rules/policies/protocols/laws belong with Parking Enforcement Officers or people who can't be bothered to take the trouble to make a considered decision in each and every case.

[/quote]

No. Policies exist to guide the lay staff when you are not available. That way they are not put in a position where they are under pressure from clients to dispense medication where the animal requires to be seen.

PS: You haven't seen my Traffic Warden uniform have you?

Re: repeat prescriptions

Clive Ansell — Tue, 18 May 2010 09:10:29 GMT

A 3, 6 or 12 month figure should be a guide thats all, with the ultimate decision based on the pros and cons of the individual case. There has to flexibility, a bit of give and take, a little slack in the system. At the same time rules and practice protocols should be followed as much as is practically possible, as many clients will try and avoid recheck appointments usually because of cost.

For example; if a case is written up for a 6 month check, is stable, and it is 5 months and 3 weeks, I would provide another months worth and say "check next time". If already over the 6 months, then I would say "needs to be seen".

Re: repeat prescriptions

Anthony Todd — Tue, 18 May 2010 08:55:08 GMT

[quote user="Louise Alexander"]but I appreciate every practice has different protocols and thought ours might be different to yours![/quote]

Yours and Clive's seem to be eminently sensible, do what's best for the animal, don't piss off the clients who often have as much medical knowledge as the vet and often more common sense.

Rigid rules/policies/protocols/laws belong with Parking Enforcement Officers or people who can't be bothered to take the trouble to make a considered decision in each and every case.

I mean, there's so many, you'd never get through your day!!!

Re: repeat prescriptions

Anthony Todd — Tue, 18 May 2010 08:43:58 GMT

[quote user="Clive Ansell"]There needs to be some form of guide or ball park figure, and I think 12 months is reasonable[/quote]

Couldn't agree more but then you quote a series of exceptions which rather agrees with me.

The trouble is when it's taken as a fixed penalty parking meter when really no harm would be done and a lot of benefit, as in your last exception.

Yeah, but you're using common medical sense, rare these days, and thinking more about the animal and less about "the law".....

Re: repeat prescriptions

Louise6732 — Tue, 18 May 2010 07:42:09 GMT

[quote user="Anthony Todd"] Is it too hard to refer each and every request to the vet for a decision [/quote]

Unless a vet answers the telephone to someone asking for a repeat prescription, (in which case they can deal with the request directly) the receptionist/nurse puts the request on the computer and a vet has to dispense the medication, reading the notes first (!) in case the last time the animal was seen they were requested to come back for a blood sample etc.

Your post sounds like receptionists/whoever answers the phone dispenses medications?

As a vet, I would occasionally have to ring the client and explained they need to be seen as it's been more than 6/12mnths, most people are fine with this. A lot of peope have a grumble but such is life, think of how strict GPs are on these issues!

Sorry if that's what you meant Anthony, but I appreciate every practice has different protocols and thought ours might be different to yours!

Re: repeat prescriptions

Clive Ansell — Tue, 18 May 2010 07:26:59 GMT

[quote user="Anthony Todd"]

It's the blanket "12 months" which infuriates me and clients and is illogical, as is any time period.

[/quote]

There needs to be some form of guide or ball park figure, and I think 12 months is reasonable. After all, responsible pet owners should be presenting their pets for an annual examination and vaccination anyway.

If 6 months of anti-parasitics are prescribed for an animal not seen for 14 months, that will be 20 months without that animal being seen, I don't think that could be seen as being "under our care" . If the client really won't or can't bring the cat in, then non prescription Frontline and Drontal are options.

I will normal prescribe flea and worm drugs up to 12 months or thereabouts, 6 months for other medications. Common sense and clinical judgement sometimes override this though.

some examples I have had:

An awkward and obnoxious client with a cat that is stable on Felimazole, who refuses to bring the cat in more than once a year when he comes for his vaccine, and refuses any blood tests to monitor. I have compromised and the client sees an RVN every 3 -4 months for a FOC weight check and heart rate measurement. Not ideal perhaps, but at least we are keeping tabs on the cats condition and can say it is "under our care", and the client is fairly OK with it.
A cat that was initially prescribed Eltroxin for obesity ( ), had repeats for 5-6 years without being seen, when it was presented emaciated, +++tachycardic, and in end stage cardiac failure. Clearly, an unacceptable level of "under our care"
A young GSD with unstable epilepsy that is on high doses of Phenobarbitone and KBr, where the practice owner had requested 3 month checks with bloods for phenobarb and KBr assays. Woman refused to bring the dog in, so went elsewhere to one of the low cost clinics where they just handed out the meds after briefly (5 min appointment) seeing the dog. I was presented with the dog in status epilepticus about a month later at one of the OOH clinics, resulting in 48 hours hospitalisation and a £600-£700 bill. The practice owner and I are both totally vindicated in our decision not to prescribe more meds without seeing the dog. The client is now trying to sue the low cost clinic for not doing what we advised in the first place!
"Muscles" an extremely ferocious and aggressive Boxer with atopy and recurring otitis externa. Any form of examination is impossible and potentially dangerous, and one just cannot do anything with it. The owner is an NHS nurse and fairly sensible, so quite happy to hand out Malaseb, Preds, Canaural, occasional antibiotic courses with 50 year rechecks

Re: repeat prescriptions

Anthony Todd — Mon, 17 May 2010 23:56:03 GMT

It's the blanket "12 months" which infuriates me and clients and is illogical, as is any time period.

How many requests do practices get in a day?

Is it too hard to refer each and every request to the vet for a decision so that "I know it's 14 months but I've been away and the cat is fine and weighs 4.2Kg so can I have a repeat of flea treatment, please" won't be greeted by "Sorry it's the law and the vet. could get sued or struck off, if it's over 12 months, so you'll have to bring your cat all the way on the bus so that the vet can give it a token examination and give you a script that has been given many times before"!!!!!!

or, even worse:

"My dog's on insulin and needs some more, she's drinking loads of water and vomiting"

"That's fine, it's within x months [fill in the "practice policy"] so it 's OK"

Refer to the vet has got to be the sensible logical and medical way.

Of course it does mean the vet has to take interest and responsibility which might be too arduous.

And as for educating clients, pleeeeeassse, explanation,yes.

Re: repeat prescriptions

Laurence Webb — Mon, 17 May 2010 23:20:55 GMT

Whenever an animal is examined we always try to write on the clinical records how long we are happy for animals to be prescibed drugs for.

If I see an animal and say that it need to be re-examined in 1 week, 3 months or 6 months then medication can be put up until that point. After that point it becomes illegal to dispense medication unless a MRCVS prescribes more medication (whether that's following an examination/blood sample/telephone call etc). The vet who last prescribed medication is liable for side effects or complications.

The owness is on the vet who prescribes medication to decide how long they are happy to treat an animal. Practice protocols are there to guide vets, nurses and lay staff but the responsibility is up to the vet who last prescribed treatment.

Re: repeat prescriptions

HMC — Mon, 17 May 2010 21:24:02 GMT

[quote user="Vikki Halliday"]

Therefore, the best way to put it to a client who is being objectionable about repeat prescriptions, (and these are the people who are probably most likely to sue your ass if it goes wrong), is to explain that the RCVS say that it is up to the individual veterinary surgeon, and in your case, you have decided that all things considered this is the appropriate length of time to leave without seeing the animal.

[/quote]

That sounds a sensible way of putting it-

but more for explaining it to others in the profession; I don't think I would include the client in the debate- if we're having pages and pages of debate (on this and previous posts) then I'd rather keep it short and sweet for the client: "practice policy" or " legal guidelines", I think!!

Re: repeat prescriptions

Vikki Halliday LLB — Mon, 17 May 2010 16:24:03 GMT

Anthony,

Sorry if I am confusing you, but I was referring to an example of a dog being prescribed insulin when having had not had an examination for a significant period of time, say 12 months. I don't think that is "sensible" as you say, but was trying to point out that regardless of clinical condition, the decision is yours.

The only reason you may want to have a practice policy is so that lay staff can answer queries about how often animals need to be seen, or if there indeed is a maximum time limit. I prefer to have reception staff say that my policy is every 3-6 months depending upon the condition, and in the case of preventative healthcare such as flea and worming treatment, up to 12 months. That way there is no way that mistakes can be made and animals slip through the net.

[quote user="Anthony Todd"]

[quote user="Vikki Halliday"]While I agree with you, there needs to be some clear definition and education of the public with regards to who makes the decision as to what length of time is acceptable, i.e. the veterinary surgeon.[/quote]

There is, it's called a degree in vet science, nothing about time at all.

[/quote]

A degree in veterinary science or medicine does not guarantee that you can educate the general public. Your own clients yes, but I was making a more general statement, aimed at the BVA/RCVS.

Re: repeat prescriptions

Anthony Todd — Mon, 17 May 2010 14:05:08 GMT

[quote user="Vikki Halliday"]I realise there are those who may well end up going to another practice with a more "relaxed" view of matters, but if they are that way inclined, they are probably not making you any money anyway.[/quote]

Your arguments confuse me. Have we set the rule/policy/law at a max of 12 months for the good of the animal or just to make money?

And substitute "sensible" for relaxed"

There is, it's called a degree in vet science, nothing about time at all.