How To Write A Prescription
When you’re filling out forms like an insurance card application, your state’s driver license form, or even an online dating profile, it can be difficult to remember how to write things in standard English. But when it comes time to fill out a medical history form, a doctor’s visit note, or something similar, the rules for spelling, capitalization, punctuation and grammar are pretty straightforward. In this article we’ll provide some tips on what makes sense when you’re writing a prescription.
First off, there are two kinds of words that doctors will need to know how to spell correctly. The first category includes proper nouns — names such as “Dr.” or “Mrs.,” last name only (“Jones”), first initial plus last name, full name with middle initial included (“John Smith”) and titles (“Ms.”) Proper nouns should always be written without any abbreviation except for periods between sentences. For example, if you were writing a prescription for Dr. John Smith, you would not say, “His period has been heavy this month.” You’d simply write, “His period has been heavy this month,” just as if he was anyone else.
The second category includes common nouns — generic terms for people, places and things such as “doctor” and “hospital,” last name only (“Smith”), title only (“Mr.”, “Miss”, etc.), first-and-last name with street address, first initial followed by street name (“2 Maple Street”), and full name with middle initial. Common nouns may be spelled with their short version, e.g., “theater” instead of “movie theater”. However, they must also include the hyphen unless they are part of another word such as “wedding photographer.” If a common noun is the subject of a sentence, it should be written in lowercase letters, e.g., “a good surgeon” rather than “good surgeons”. It is permissible to capitalize common nouns at the beginning of a sentence, but this is usually done to make them stand out, e.g., “We went to see a movie today, and had fun!”
Here is a list of abbreviations that most physicians understand and prefer to use. Many others exist, however, so be sure to check with your physician before starting treatment.
ADHD = Attention Deficit Hyperactivity Disorder
AIDS = Acquired Immune Deficiency Syndrome
AO/VO = Arterial Oxygen Venous Obstruction
ASTM = American Society for Testing and Materials
BCG = Bacille Calmette-Guérin vaccine
BPH = Benign Prostatic Hypertrophy
CABG = Coronary Artery Bypass Graft Surgery
CHF = Congestive Heart Failure
COPD = Chronic Obstructive Pulmonary Disease
CRP = C-reactive Protein
CT = Computed Tomography
DDT = Dichlorodiphenyltrichlorethane
DEA = Drug Enforcement Administration
DNA = Deoxyribonucleic Acid
EOB = End Of Billing
ER = Emergency Room
EURO = Euro
FDG = Fluorodeoxyglucose
FFP = Fresh Frozen Plasma
HIV = Human Immunodeficiency Virus
ICU = Intensive Care Unit
IGRT = Immediate Postoperative Radiotherapy
IM = Intramuscularly
MRI = Magnetic Resonance Imaging
NHLBI = National Heart, Lung, And Blood Institute
NSAIDs = Nonsteroidal Antiinflammatory Drugs
PCOS = Polycystic Ovarian Syndrome
PM&CC = Primary Medical & Clinical Conditions
PPD = Purified Protein Derivative Vaccine
RFA = Radiofrequency Ablation
RNA = Ribonucleic Acid
SD = Standard Deviation
SEX = Sexual Activity
SPECT = Single Photon Emission Computerized Tomography
TB = Tuberculosis
TC = Total Cholesterol
THC = Tetrahydrocannabinol
TSHT = Testosterone Suppression Hypnotics Therapy
VAS = Visual Analogue Scale
VDL = Very Low density Lipoprotein
WBC = White Blood Cell Count
Yrs. = Years
There are several other abbreviations that many physicians understand, but they tend to be regional favorites, such as: AR = allergic reaction; B12 = vitamin B12 deficiency; CBC = complete blood count; CPAP = continuous positive airway pressure therapy; CT scan = computed tomography scan; EOB = end of billing; ER = emergency room; FSH = follicle stimulating hormone; Hgb = hemoglobin; ICD = implantable cardioverter defibrillator; MRI = magnetic resonance imaging; NSAIDS = nonsteroidal antiinflammatory drugs; PSA = prostate specific antigen; RFA = radiofrequency ablation; SEX = sexual activity; WBC = white blood cell count
Now that you have learned about basic vocabulary, you can take a crack at writing a few sample prescriptions. Just follow these steps:
1. Start your prescription at “Dear Doctor” and sign it “Sincerely Your Name.”
2. State your reason for visiting the doctor.
3. Write your date of birth.
4. List all medications that you are taking. Medications should be listed according to the order that you took them. Include over-the-counter medicines and herbal supplements as well.
5. Check the boxes next to each medication you want to continue. Leave those you don’t want to take unchecked.
6. Under “Primary Medical & Clinical Conditions” add any conditions or ailments that are currently bothering you. This section will help the doctor better care for you.
7. Add new diagnoses in the space provided below.
8. Enter information about past illnesses or injuries under “Past Illnesses” or “Present Illnesses.”
9. Make notes about allergies, particularly drug allergies. Be very descriptive when listing allergies.
10. Record any surgeries and physical examinations you’ve undergone.
11. Describe symptoms associated with these conditions. Don’t forget to describe pain, changes in appetite, nausea, weight loss, itching, swelling, rash, numbness, tingling, tightness, weakness, burning, discomfort, stiffness, sensitivity to touch, vision problems, dizziness, ringing in the ears, chest pains, chills, fever, diarrhea, constipation, flatulence, belching, drooling, difficulty swallowing, coughing, breathing difficulties, urinary incontinence, fatigue, anxiety, depression, nervousness, confusion, trouble sleeping, or anything else that might seem important.
12. Enter information about current health concerns. These should be brief, factual statements describing the problem. Use bulleted lists whenever possible.
13. Explain how long you’ve had the condition, how often it occurs, its severity, and any complications. Also give approximate dates of onset.
14. Specify whether symptoms are acute or chronic. Acute symptoms generally occur suddenly with rapid resolution and do not recur. Chronic symptoms last more than six weeks or become progressively worse.
15. Mention any family history of genetic disorders, including cancer, diabetes, heart disease, high cholesterol, hypertension, kidney diseases, liver diseases, neurological disorders, rheumatoid arthritis, stroke, thyroid conditions, or dementia.
16. Give detailed descriptions of signs that could indicate organ damage, injury, infection, poisoning, obesity, malnutrition, and abuse.
17. Indicate which organs or parts of the body are involved.
18. Note special tests, procedures, or treatments that you have already received.
19. If applicable, explain why you didn’t receive previous treatment.
20. Request test results or lab measurements. Ask specifically for test numbers and reference ranges.
21. Discuss side effects of medications. Symptoms must be clearly described.
22. Report symptoms that did not improve after three visits.
23. Thank the doctor for his or her attention.
24. Sign your name, initials, and date at the bottom of the page.
25. Mail the original prescription within 48 hours of your appointment.
26. Send copies of your records to yourself or someone who can keep up with them.
27. Follow up with the doctor via email or phone call.
28. Take your new prescriptions to a pharmacist for review.
29. Do not share your prescription with anyone else. Never go beyond the pharmacy counter to pick up your prescription.
30. Keep your records safe. They must never be thrown away.
31. Get all of your prescription refills mailed together. Do not separate them into different envelopes.
32. Read your prescription carefully. Know exactly what you are supposed to do.
33. Consult your doctor immediately if you experience severe reactions to medications.
34. Inform your doctor of any significant life events during the course of your illness. This is especially true if you have experienced surgery, radiation, or chemotherapy.
35. Carry identification showing your
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