Writing a prescription

Writing a prescription

A prescription is a documented record of medications or treatment instructions prescribed to a patient during their medical case (clinic visit, hospital admission, or emergency encounter). You can write prescriptions directly within the patient's medical case in Usystems.

Before you start

• Ensure you have clinical access to the patient's medical case (this requires appropriate user role permissions).
• Have the patient's details at hand: existing allergies, current medications, and any contraindications.
• Know the medication names and dosages you want to prescribe (or access your facility's medication reference).
• Be aware of your facility's prescription writing standards or protocols (if any).

Steps

1. Open the patient's Medical Case from the Patients list or dashboard. Open in Usystems

2. Locate the Prescriptions section within the medical case (usually a tab or expandable panel).

3. Click Add Prescription or New Prescription to open the prescription form.

4. Fill in the prescription details:

   • Medication name: Enter the drug name (e.g., "Amoxicillin," "Paracetamol"). The system may provide a dropdown list if your facility maintains a medication master list.
   • Dosage: Specify the dose and unit (e.g., "500 mg," "2 tablets").
   • Frequency: How often the patient takes the medication (e.g., "twice daily," "every 6 hours," "as needed").
   • Duration: How long the patient should take the medication (e.g., "7 days," "2 weeks").
   • Route: Method of administration (e.g., oral, injection, topical, inhalation).
   • Special instructions (optional): Any additional guidance (e.g., "take with food," "avoid dairy," "discontinue if rash develops").

5. If needed, add any notes about the prescription (e.g., reason for prescribing, special monitoring needed).

6. Click Save to record the prescription in the medical case.

7. The prescription is now part of the patient's record and can be printed, reviewed, or edited later.

Editing or canceling a prescription

• To edit a prescription, click the prescription entry, make changes, and click Save.
• To cancel or remove a prescription, use the Delete or Cancel option (if available in your product version). This typically records the cancellation in the patient's history.

Tips & common mistakes

• Check for drug interactions: Before prescribing, verify that the new medication does not interact with the patient's existing medications.
• Document special instructions clearly: If the patient has allergies or needs special handling (e.g., "take on empty stomach"), note it in the prescription to avoid confusion during dispensing.
• Use standard abbreviations cautiously: Some abbreviations (e.g., "QID" for four times daily) may not be recognized in all regions. Use plain language (e.g., "four times daily") when possible.
• Review before printing: Always verify the prescription details are correct before printing or dispensing to the patient.