Ebook Pharmacy technician exam certification and review: Part 2

Medication Order Entry and Fill
Process
CHAPTER

6
PTCB KNOWLEDGE AREAS
6.1 Order entry process
6.2 Intake, interpretation, and data entry
6.3 Calculate doses required
6.4 Fill process (eg, select appropriate product, apply special handling
requirements, measure, and prepare product for final check)
6.5 Labeling requirements (eg, auxiliary and warning labels, expiration date,
and patient-specific information)
6.6 Packaging requirements (eg, type of bags, syringes, glass, pvc, child
resistant, and light resistant)
6.7 Dispensing process (eg, validation, documentation, and distribution)

KEY TERMS
Admitting order: Type of medication order written upon admission into a
facility which contains previous medications being taken, new medications
being ordered, any laboratory or diagnostic tests desired by the physician,
and a suspected diagnosis
Automated dispensing cabinets (ADCs): A storage cabinet containing
medications needed for patients in specific nursing units in which nurses
can retrieve mediations in an efficient manner
Auxiliary labels: Brightly colored labels designed to provide additional
warnings to patients
Blended unit dose: A unit dose system which packages all the patient’s
medications to be taken at the same time together

Computerized physician order entry (CPOE): Prescription orders entered
by the prescriber into the pharmacy computer system directly
Counting tray: Device used to count solid oral dosage forms such as tablets
or capsules
Days supply: The number of days a medication should last if used correctly
Discharge orders: Type of order given upon being discharged from the
hospital
Expiration date: The date indicating when the effectiveness of a medication
will diminish
Inscription: Part of the prescription that contains the name and strength of the
medication and the amount prescribed
Legend drug: A drug which requires a prescription to be dispensed
Medication administration record (MAR): A record of each time a
medication is administered to a patient (used in an inpatient setting); shows
what time the dose was given and who administered the dose
Medication order: An order for a patient written for the inpatient setting
Modified unit dose: Also known as a blister or bingo card, a unit dose
system which provides a month’s supply of a medication into one card
Over-the-counter (OTC) drug: A drug which does not require a
prescription to be dispensed
Patient profile: Record of information of a patient, including basic
demographics, prescription filling history, allergy, and insurance
information
Prescription: An order for a patient in the outpatient setting, written by a
qualified health care professional and filled by a registered pharmacist
PRN orders: Type of medication order given only as needed
Scored: Tablets which have a line or crevice through the center which makes
dividing the tablet in half easier and more accurate
Sig codes: Certain abbreviations for directions written on prescriptions,
designed to help simplify and speed up the order entry process

Signa: Also known as sig, the part of the prescription that contains directions
to the patient
STAT order: Type of medication order written for a drug that is needed
immediately
Subscription: Part of the prescription that contains directions to the


pharmacist such as refills or dispense as written (DAW) requirements
Superscription: Part of the prescription that is the Rx symbol
Tablet splitter: Device used to split tablets for patients taking half-tablet
dosages
Unit dose: A medication that has been prepackaged for a single-dose
administration
Unit dose cart: The cart filled by the pharmacy for usually a 24-hour supply
of medication, and used by the nurses to pull medications from the drawers
for each patient
Unit dose drug distribution system: A system which utilizes a cart of
drawers containing unit doses specific for each patient in a hospital unit
Unit-of-use: A method of packaging of medications in a fixed number of
units that is the most commonly prescribed amount, that is, prepacking a
bottle of 30 for a medication taken daily

CASE STUDY
A patient brings a prescription into the pharmacy. You attempt to read the
directions as appear in Figure 6-1.

FIGURE 6-1 Handwritten prescription.
Self-Assessment Questions

• What is this drug written for?
• What is the strength?
• What are the directions?
• How many should be dispensed and are refills permitted?
After completing this chapter, you should be able to answer the case study
assessment questions presented for the illegible prescription of Figure 6-1.

INTRODUCTION
There are many processes involved in medication order entry and the filling
process. This chapter focuses on all the necessary steps in prescription
processing, including dosage calculations, abbreviations, packaging, and
labeling requirements. After completing this chapter, you should be confident
with the process of filling prescriptions and entering medication orders.

ORDER ENTRY PROCESS
A pharmacy technician plays an essential role in entering prescriptions
properly into the computer, updating all patient information while ensuring the
patient profile is accurate, and providing excellent customer service. By
properly completing these and other delegated tasks, the pharmacy technician
can successfully free up time for the pharmacist to spend counseling patients
about medication-related questions.
* TECH ALERT: Remember, as a pharmacy technician
you have many responsibilities, but you must never
counsel patients. Only the pharmacist is permitted to
counsel patients.
As a technician, you will encounter 2 different types of orders in the
pharmacy setting. In the outpatient setting, a patient will present a prescription
written by a licensed medical practitioner; whereas, inpatient requests for
medications are known as medication orders. Prescriptions in the outpatient
setting are required for any legend drug. A legend drug is a drug which

requires a prescription to be dispensed. Only nonprescription drugs or overthe-counter (OTC) medications are dispensed legally without a prescription.


Parts of the Prescription
A pharmacy technician provides the first look at the accuracy and
completeness of a prescription.
The necessary components of a prescription are listed in Table 6-1:
TABLE 6-1. Required Components of a Prescription
1. Prescriber information: Name and address of office, phone number
2. Prescriber’s Drug Enforcement Administration (DEA) number (for
controlled prescriptions)
3. Date
4. Patient information: Name, address, telephone number, and date of birth
5. Inscription: Medication prescribed, name, quantity, strength, and amount
6. Superscription: Rx symbol
7. Subscription: Directions to the pharmacist, refills or special labels
8. Signa (sig): Directions to the patient
9. DAW: Dispense as written
10. Prescriber’s signature
Figure 6-2 shows an example prescription from a medical doctor. The
technician reviews the prescription for completeness and then enters the
information into the computer. The figure shows each important component to a
prescription which is necessary for processing:
1. Prescriber information includes the address of the physician, office phone
number, and a fax number.
2. Prescriber’s DEA number for this prescription is not required because
Topamax is not a controlled substance. A DEA number is issued by the Drug
Enforcement Administration to a prescriber. This allows the physician to
prescribe controlled substances. The DEA number is usually not preprinted
on a prescription to prevent forgeries.

3. The date the prescription was written needs to be recorded. If no date is
written on the prescription, the patient should be questioned as to when the


physician was seen. If the prescription is for a controlled substance, the
date is especially important, as schedules III to V medications can only be
filled a maximum of 5 times within 6 months.
4. It is important to have a patient’s full name and address updated in the
pharmacy system. If this is not written on the prescription, the technician
should ask the patient to verify the address. If the birthdate is not written on
the prescription, the technician must request this information from the
patient. This is essential for billing and insurance purposes, but also allows
the pharmacist to verify the proper dosage of a medication.
5. The inscription is the part of the prescription that contains the name and
strength of the medication and the amount prescribed.
6. The superscription is the Rx symbol located on every prescription.
7. The subscription is the part of the prescription which lists directions to the
pharmacist. These could include specific labeling requirements or
instructions or refill information.
8. Directions to the patient are known as the signa or more commonly sig for
short. This is the code that is translated from the prescription to the label
into a more easily read format for the patient.
9. DAW is dispense as written. A prescriber will indicate this if they
specifically want the brand name product to be dispensed. Patients may also
request the brand name product be dispensed even when a generic is
available, (and acceptable by the physician). These situations are discussed
more in Chapter 9 discussing insurance billing.
10. Each prescriber must sign the prescription legibly not just able to be
recognized. If a prescription is faxed, the signature may be electronic for all
medications except controlled substances.

FIGURE 6-2 Patient’s prescription.

Intake, Interpretation, and Data Entry
In the outpatient setting, technicians are responsible for completing the steps to
ensure proper prescription processing. This begins with receipt of a
prescription from the patient or patient’s representative. It is important for a
technician to gather as much information during this step as possible.
A pharmacy technician is also responsible for updating and maintaining the
patient profile. There are many important pieces of information that should be
gathered from the patient, and maintained as the patient continues to fill
medications. Some typical information on the patient profile includes the
following:


• Patient’s name (including middle initial and Jr./Sr. for verification
purposes)
• Date of birth
• Home address and working phone number where patient can be reached
• Insurance and billing information
• Allergies
• Diagnoses
• Any OTC medications currently being taken by the patient
• Preferences for easy-off caps
After a technician has updated the profile, he or she will then enter the
prescription information into the computer system. The technician should
verify the correct drug, strength, and dose was entered into the system,
carefully double-checking against the original prescription.
* TECH ALERT: It is important to ask for help when

reading an order that is difficult to interpret. You should
never assume when reading prescriptions. The pharmacist
relies on your knowledge to help keep patients safe.
Always ask “What do you see” rather than “Do you see
this?”
When entering prescription information into the system, most pharmacy
software programs will recognize certain abbreviations for directions, to help
simplify and speed up the order entry process. These are referred to as sig
codes, and although the exact abbreviation may differ depending on the
pharmacy, most follow a similar format (Tables 6-2, 6-3, 6-4 and 6-5).
TABLE 6-2. Medication Administration Abbreviations


TABLE 6-3. Dosage Forms and Route of Administration Abbreviations



TABLE 6-4. Measuring Quantities

TABLE 6-5. Medication Abbreviatons


Error-Prone Abbreviations
As discussed in Chapter 5, although you may still encounter these
abbreviations, the Institute for Safe Medication Practices considers the
following abbreviations as being frequently misinterpreted and involved in
medication errors. A pharmacy technician should take great care when reading
prescriptions that use any dangerous abbreviations. Table 6-6 lists a few
examples of commonly used dangerous abbreviations.
TABLE 6-6. Dangerous Abbreviations

QUICK QUIZ 6-1
1. Which part of the prescription contains the medication name and strength?
2. What is the abbreviation for twice daily?
3. What is a prescription called in the hospital setting?
4. What does the abbreviation gtt mean?
5. What part of the prescription contains the directions to the patient?

PHARMACY DOSAGE CALCULATIONS
When entering the prescription information into the pharmacy system, a
technician must often perform certain calculations to determine proper
dosages, amount to dispense, or days supply. Often, the prescriber will
indicate the amount to dispense in Roman numerals. Or possibly the prescriber
could specify the number of days a medication is to be given and the dosage


taken, but the pharmacy must determine the quantity to dispense based on this
information. A technician must perform these calculations carefully and swiftly
to provide excellent and safe customer service to our patients.
* TECH ALERT: Remember, if a prescription is written
for a controlled substance, the numerical number and
written quantity must both be written on the prescription,
for example, #20 (twenty).
A prescription is brought into the pharmacy with the directions take 2
tablets bid × 7 days. In order to calculate how many tablets the patient will
need, we first need to calculate how many tablets the patient will be taking in 1
day. We can do this by multiplying the dose by the frequency of administration.
Dose = 2 tablets
Frequency = bid (twice daily)

2 tablets × 2 daily = 4 tablets daily
To determine the total quantity needed for this prescription, we will
multiply our daily quantity by the number of days of therapy.
Daily amount = 4 tablets
Days of therapy = 7 days
4 tablets × 7 days = 28 total tablets needed
We can also calculate the days supply of a medication, which is the number
of days a medication should last if it is used correctly. This is an important
quantity to determine for insurance and third party payers that have limits to
how much they will cover in a specified period.
A prescription is written for ampicillin 500 mg 1 cap qid #28. What is the
days supply of this medication? Another way to look at this would be, how
long will this medication last if the patient takes each dose properly? To find
the days supply, first determine how many units will be taken in 1 day.
Dose = 1 capsule
Frequency = qid (4 times daily)
1 capsule × 4 times daily = 4 capsules daily
Next to determine the amount of days this medication will last, divide the
total quantity dispensed by the daily quantity taken.


Daily amount = 4 capsules
Amount of medication to dispense = 28 capsules
28 capsules ÷ 4 capsules = 7 days supply
The same calculations can be done for liquid dosages as well. Remember
the conversions for household volumes:

If a prescription calls for a suspension to be given 1 tsp tid × 10 days and
the prescriber writes QS on the prescription, the pharmacy must determine the
total volume to dispense for a quantity sufficient (QS) for the entire therapy.

The same process is done as with any solid dosage form. First find the quantity
taken in 1 day and then multiply this by the total days to determine the total
volume needed.
Dosage = 1 tsp = 5 mL
Frequency = tid = 3 times daily
5 mL × 3 times daily = 15 mL daily
15 mL daily × 10 total days = 150 mL
150 mL needed for 10 days of therapy
The same can be done for days supply. If a prescription calls for a
medication to be taken 2 tbsp bid, dispense 300 mL, how long will this order
last the patient?
Dosage = 2 tbsp = 30 mL
Frequency = bid = twice daily
30 mL × twice daily = 60 mL daily
300 mL ÷ 60 mL = 5 days supply
Additionally, technicians may need to calculate days supply and dosages
with calculations involving insulin. The standard concentration for most insulin
100 units per every 1 mL. Insulin vials are usually 10 mL (1,000 units) while
insulin pens are usually 3 mL (300 units). Therefore, for example, if a patient
is taking 20 units of insulin daily, and the pharmacy needs to calculate the days


supply when dispensing 1 insulin vial, we can utilize the same concepts as
before to determine this amount.
Dosage = 20 units
Frequency = daily
20 units per day
Total units per insulin vial = 100 units/1 mL × 10 mL vial = 1000 total units
1000 units/20 units per day = 50 days supply
Technicians may also encounter days supply issues when dispensing eyeand eardrops. To solve days supply for these medications, it is essential to

know how many drops are in 1 mL. This number varies based on the
medication and physical properties of the solution or suspension. Therefore,
for most insurance claims, pharmacies use the conversion 1 mL = 20 drops.
However, this is an estimation only so it should not be used for any dosage
calculations, but merely an approximation of how long the medication will last
the patient.
If a prescription is written for an eyedrop to be given 1 gtt OU qd, dispense
5 mL, what is the days supply?
Dosage = 1 gtt = 1 drop
Frequency = OU = both eyes = 2 drops daily
2 drops daily

100 drops total in 5 mL
100 drops/2 drops daily = 50 days supply

QUICK QUIZ 6-2
1. If a prescription is written for amoxicillin 1 cap tid × 10 days, how many
capsules should be dispensed?
2. A prescription is written for Omnicef suspension to be given 1 tsp qd,
dispense 50 mL. What is the days supply for this medication?
3. An order is written for Bactrim suspension 3 tsp bid × 10 days QS. How


much should be dispensed to this patient?
4. If a patient is given a prescription for an eyedrop to be given 1 gtt OU qid,
dispense 10 mL, what is the days supply for this bottle?
5. If a patient is getting 25 units bid of insulin, is 1 vial enough to last them 30
days?

LABELING REQUIREMENTS

After the order has been entered into the pharmacy system, a label will be
generated with the key information from the prescription. There are legal
requirements for components of the prescription label (Figure 6-3). The
required label information includes the following:
• Pharmacy’s name and address
• Pharmacy’s phone number
• Computer-generated prescription number (Rx number)
• Date when the prescription was filled
• Patient’s name
• Directions for use of medication
• Name and strength of medication
• Quantity of medication dispensed
• If generic is filled, name of the drug manufacturer
• Refill information
• Name of the prescribing physician
• Initials of the pharmacist verifying the prescription


FIGURE 6-3 Prescription
In addition to the prescription label, auxiliary labels can be used to provide
additional warnings to patients. These labels can help communicate directions
on administration, storage information, or special instructions that a patient
may be unaware of. Auxiliary labels are brightly colored to stand out on the
prescription bottle (Figures 6-4 and 6-5).


FIGURE 6-4 Prescription bottle label.

FIGURE 6-5 Auxiliary labels.

FILL PROCESS
The fill process is a multi-step process that requires attention to detail to
ensure accuracy. After the label has printed, it should be verified against the
original prescription to check for any discrepancies. The technician then pulls
the appropriate medication from the shelf and, using the National Drug Code
(NDC) number from the stock bottle, verifies that the correct medication was


selected. A technician should never assume the correct stock bottle was
chosen, and compare only the drug name and strength with the label (Figure 66).

FIGURE 6-6 Stock bottle label.
The stock label on the bottle will give pertinent information that is essential
for technicians in many situations.
1. NDC number
2. Brand name, generic name in parentheses
3. Manufacturer
4. Dosage form
5. Lot number
6. Expiration date
7. Strength per unit
8. Bar code
9. Rx only label
10. Storage requirements
If the medication is a solid dosage form, such as a tablet or capsule, a
counting tray will be used to transfer the drug from its stock bottle to the
prescription container (Figure 6-7). Medications are generally counted in
multiples of 5. A counting tray and spatula should be cleaned with 70%
isopropyl alcohol to prevent cross contamination of medications, especially

those which leave a powder residue. Because of the severity and frequency of
patient allergies, it should always be cleaned after counting sulfa or penicillin
drugs.

FIGURE 6-7 Counting tray.
Occasionally, patients may be prescribed half-tablets. In this case, the
pharmacy may direct the patient to purchase a tablet splitter (also referred to
as a pill cutter) to cleanly split the tablets, especially those which are scored
(Figure 6-8). A scored tablet is one which has a line through the center,
allowing the tablet to be easily split in 2 (Figure 6-9).


FIGURE 6-8 Tablet splitter.

FIGURE 6-9 Scored tablet.
Pharmacy vials (Figure 6-10) come in several different sizes, and the vial
chosen for each prescription should be the smallest size which can hold the
medication without overfilling. The vials are arranged based on quantity held
using the apothecary dram system. They range in size from 6 to 60 drams and


are generally amber in color. The amber vials are light resistant which protects
medications from contamination due to excessive light transmission.

FIGURE 6-10 Pharmacy vials.
A technician will fill the pharmacy vial with the medication and then select
the appropriate lid. If a patient or physician has requested easy-off caps, the
prescription will not be child resistant. Patients will receive child-resistant
caps unless they have requested otherwise by signing a waiver. This document

is kept on file within the pharmacy, as well as listed on the patient profile for
future prescription filling. Certain medications are permitted to be dispensed
with a nonchildproof lid, such as oral contraceptives, inhalation aerosols, and
sublingual nitroglycerin.
* TECH ALERT: Sublingual nitroglycerin should always
be dispensed with an easy-off cap, so it is easily
accessible during emergencies.
For liquid medications, pharmacy bottles are measured in fluid ounces, and
generally range in size from 2 to 16 oz (Figure 6-11). These bottles are also
amber colored to protect liquid medications from exposure to ultraviolet (UV)
light.


FIGURE 6-11 Pharmacy bottles.
Medications can also come in unit-of-use packaging, which is provided by
the manufacturer in the most commonly dispensed unit (Figure 6-12). The
package is simply labeled with the pharmacy label, without any further
modifications, eliminating the need to do any counting and thus minimizing the
risk of human error. Examples of unit-of-use packaging include manufactured
bottles of 30 for a medication taken daily, oral contraceptives, or monthly
packs of osteoporosis or antidepressant medications.


FIGURE 6-12 Unit-of-use packaging.
After the medication has been counted carefully and properly filled into the
appropriately sized container, the label is applied to the vial and the
prescription is sent to the pharmacist for final verification. Each prescription
must be checked by a pharmacist before being dispensed to the patient. A
technician should always ask the patient if they would like counseling from the
pharmacist, or have any questions in regards to their prescription. In every

pharmacy, there is a special consultation area which is a secluded space for
the pharmacist to have a private conversation with a patient.
When an order is being prepared, a patient may decide to wait for the
prescription or return later for pickup. It is important that regardless of who
picks up the order, the correct patient is verified to ensure the right medication
is delivered to the right person. Additionally, most insurance providers will
request a signature of the person receiving the medication and depending on the
coverage of the patient, a co-payment may be due.
A technician should also be mindful of where a prescription is stored while
waiting to be picked up. Prescriptions stored at room temperature are
generally alphabetized by last name in a specific holding area. Drugs that
require storage between temperatures of 2°C and 8°C will be kept in the
refrigerator. If a suspension is ordered for a patient, it should not be mixed
with water until the patient arrives to pick up the order. The expiration date