A good digital prescription is legible, complete, linked to the right patient and traceable: you know who prescribed what, when, and what was dispensed. Best practice is as much about organisation (who prescribes, who checks, who dispenses) as about the software. This guide is written for managers and heads of department: the choice of treatment remains the prescriber’s.
Key takeaways
- A complete prescription identifies the patient, the prescriber, the medicine, the dosage and the duration.
- Going digital removes illegible handwriting, not ambiguous abbreviations.
- The circuit must be written down: prescribing, checking, dispensing, administration, billing.
- Only people authorised by regulation prescribe, each with their own account.
- A paper prescription pad is still needed for system outages.
Why move to digital prescriptions
A handwritten prescription has three well-known problems: it can be misread, it can be lost, and it leaves no usable record. Digital prescribing solves all three, provided it is well organised.
Example: in a 25-bed clinic in Kumasi, the pharmacist regularly calls doctors to decipher a dosage. Once prescriptions are typed and printed, those calls become rare, and every prescription can be found in the electronic patient record at the next visit.
What a complete prescription contains
The exact mandatory items are set by each country’s regulations: check them with your medical and pharmacy regulators, such as the Pharmacists Council of Nigeria or the Pharmacy Council in Ghana. The table lists the items usually found on a complete prescription.
| Item | Why it matters |
|---|---|
| Prescriber details: name, qualification, department, contact | The pharmacist can reach the prescriber with a question |
| Patient details: name, age or date of birth, record number | Prevents dispensing to the wrong patient |
| Date of prescription | Places the prescription and its validity in time |
| Medicine name, form and strength | Avoids confusion between similar products |
| Dosage and route of administration | States how and how often the treatment is taken |
| Duration of treatment or quantity | Allows the right quantity to be dispensed |
| Weight, when needed (for example in paediatrics) | Useful for the pharmacist’s check |
| Signature and stamp | Commits the prescriber’s responsibility |
Example: a polyclinic in Port Harcourt adds the record number to every printed prescription. When a patient returns to the pharmacy with a question, the pharmacist finds the original prescription immediately. In Ghana, the same discipline helps check that items prescribed to NHIS members appear on the scheme’s medicines list before the claim is submitted.
Writing rules
Unambiguous medicine names
Write the medicine name in full, for example using the international non-proprietary name (INN), with form and strength. Pick lists speed up entry but carry a risk: selecting the line next to the right one. A final read-through before validation remains essential.
No ambiguous abbreviations
Digital prescribing fixes handwriting, not abbreviations. An abbreviation understood in one ward can be misread in another. Draw up a short list of approved abbreviations, display it and ban all others. Example: “1 tab x 3” can be read several ways, while “1 tablet three times a day for 5 days” can only be read one way.
One line, one medicine
Each medicine has its own line, with its dosage and duration. Instructions such as “repeat” or “as needed” are spelled out: how many times, under what conditions, until when.
The prescription circuit, from doctor to pharmacy
Prescribing is only one step in a circuit that must be written down and known to everyone. Here is a typical sequence, to adapt to your facility.
- The doctor enters the prescription in the patient’s record and validates it under their own account.
- The prescription is printed, signed and handed to the patient, or sent to the in-house pharmacy according to your procedure.
- The pharmacist checks the prescription and contacts the prescriber if in doubt.
- Dispensing is recorded as a stock issue, with the batch number.
- For inpatients, the nurse records each administration.
- Dispensed medicines are billed in naira or cedis, or charged to the patient’s cover (NHIS, NHIA or HMO).
Every step leaves a trace, so you can trace back from the patient to the batch dispensed. Example: in a district hospital, skipping step 4 caused unexplained stock gaps at every month end; once each issue is recorded, the gaps can be explained. This link is covered in our articles on medicine traceability and on avoiding stock-outs and expiries in hospital pharmacy.
Prescribing rights, access and backup procedure
Only people authorised by your country’s regulations may prescribe, and software access rights must reflect those rules. Each prescriber uses their own account: a shared account makes the prescription anonymous and responsibility impossible to establish.
A validated prescription should never be deleted. If it changes, it is stopped or amended while keeping the history. Finally, keep paper prescription pads for outages, with re-entry as soon as the system is back. Example: a clinic in Ibadan keeps a numbered paper pad in every consulting room, checked monthly by the matron.
Prescriptions and MediFlow
MediFlow does not yet offer patient records or a consultations module: both are planned. Clinical pharmacy is in development.
Today, MediFlow covers on-call management (rosters, attendance, lateness, handovers, operational checks) and the stock room (catalogue, stock movements, inventories, batches, expiry dates, reorder alerts, stock-out forecasts). The stock room already tracks product batches and expiry dates. The prescribing practices in this article apply whatever the medium, paper or software.
Frequently asked questions
Does a prescription printed from the software need to be signed?
In practice, yes: the prescription given to the patient carries the prescriber’s signature and stamp. Whether a purely electronic prescription is valid depends on each country’s regulations. Until this is clearly established where you work, keep the handwritten signature.
Can a nurse enter a prescription on the doctor’s behalf?
That depends on your country’s regulations and your internal procedure. If verbal orders are allowed in emergencies, the nurse records the order with the doctor’s name, and the doctor then validates it in the record within a set time. Software access rights should reflect these rules.
How should prescriptions be handled during a system outage?
Use numbered paper prescription pads, kept in every consulting room and known to all staff. As soon as the system is back, each paper prescription is re-entered in the patient’s record, and the pharmacy records the matching issues to bring its stock up to date.
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