Medication Transcribing Policy

Transcription

1 Medication Transcribing Policy

2 (Medication) Transcribing Policy Document Type Policy Unique Identifier MED-037 Document Purpose To provide clear guidance on who can transcribe, appropriate situations for transcribing and the correct process for transcribing medicines information for patients under the care of Worcestershire Health and Care NHS Trust. Document Author Andrew Down, Deputy Chief Pharmacist Target Audience All staff and services involved in the administration of medicines and the handling of medicines regimen information, Responsible Group Medicines Management and Safety Sub-Committee Date Ratified November 2016 Expiry Date November 2019 The validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (hacw.nhs.uk.). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version. If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on or by to (Medication) Transcribing Policy; version 2 Page 2 of 23

3 Version History Version Circulation Job Title of Person/Name of Group circulated to Brief Summary of Date Change v1 6/4/16 Transcribing Policy Review Group: Quality Lead for Adult Mental Health and Learning Disabilities; Consultant in Palliative Medicine; Non-Medical Prescriber Additions and amendments to policy: Responding to Cromwell House; Clinical Lead Nurse Redditch & transcribing errors Bromsgrove Enhanced Care Team; Care Manager Wyre Forest Enhanced Care Team; Clinical Nurse Specialist Expiry/refreshing transcribing Palliative Care; Clinical Care Co-ordinator Worcester competence Enhanced Care Team Clarification of transcribing situations Clarification of staff responsibilities Improved protocol Relationship to other policies v2 8/6/16 Supervisory Ward Managers Meeting No amendments Draft 1 15/6/16 Community Leads Workshop Meeting No amendments 15/7/16 Chief Pharmacist Minor amendments v2 Draft 2 v2 Draft 2 19/7/16 Service Delivery Unit Lead Community Care South Worcestershire 25/7/16 Transcribing Policy Review Group; Clinical Care Co-ordinator - Worcester, Droitwich and Ombersley Integrated Care Team; Matron/Clinical Lead Timberdine Community Unit; Specialist Clinical Pharmacist Community Hospitals; Senior Pharmacist Medicines Safety; Nurse Evesham Enhanced Care Team (Transcriber); Manager Churchview; Nurse Osborne Court (Transcriber); Manager Osborne Court; Deputy Directors of Nursing; Manager Keith Winter House (Transcriber); Deputy Ward Manager Athelon; Interim Head of Corporate Nursing and Education; Manager New Haven Functional; Ward Manager Lickey; Ward Manager Cottage; Deputy Ward Manager Malvern Community Hospital (Transcriber); Specialist Clinical Pharmacist Timberdine Community Unit; Clinical Lead Psychiatric Assessment Team (Transcriber); Service Delivery Unit Lead Community Care South Worcestershire; Clinical Service Locality Manager; Team Manager Adult Mental Health Specialist Community Teams; Service Lead Community Services Worcester and Droitwich; Senior Occupational Therapist Promoting Independence Service; Primrose at Home Manager; Director of Care Primrose Hospice; Deputy Ward Manager Harvington (Transcriber). 26/7/16 Clinical Services Operational Lead Community Care Service Delivery Unit South Worcestershire; Clinical Services Operational Lead Community Care Service Delivery Unit North Worcestershire; Quality Lead Children, Young People and Families, and Specialist Primary Care; Governance Manager Clarification of SDU Lead role Amendment of minor errors, inc spelling mistakes Clarification of wording Inclusion of referral to Being Open and Duty of Candour Policy No amendments (Medication) Transcribing Policy; version 2 Page 3 of 23

4 v2 (Final) v2 (Final) Adult Mental Health and Learning Disabilities Service Delivery Unit; Quality Lead Adult Mental Health and Learning Disabilities Service Delivery Unit; Lead Practitioner Quality Lead Learning Disabilities Service; AHP Clinical Lead Evesham & Pershore Enhanced Care Team. 15/8/16 Lead for Corporate Nursing (Community Services); Senior Pharmacist Medicines Safety; Registered Nurse Hospital at Home Enhanced Care Team. Approved 23/8/16 Medicines Management and Safety Sub-Committee Approved 19/10/16 Medical Director Approved Accessibility Interpreting and Translation services are provided for Worcestershire Health and Care NHS Trust including: Face to face interpreting; Instant telephone interpreting; Document translation; and British Sign Language interpreting. Please refer to the intranet page: for full details of the service, how to book and associated costs. Training and Development Worcestershire Health and Care NHS Trust recognises the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training. All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development. Co-production of Health and Care Statement of Intent The Trust expects that all healthcare professionals will provide clinical care in line with best practice. In offering and delivering that care, healthcare professionals are expected to respect the individual needs, views and wishes of the patients they care for, and recognise and work with the essential knowledge that patients bring. It is expected that they will work in partnership with patients, agreeing a plan of care that utilises the abilities and resources of patients and that builds upon these strengths. It is important that patients are offered information on the treatment options being proposed in a way that suits their individual needs, and that the health care professional acts as a facilitator to empower patients to make decisions and choices that are right for themselves. It is also important that the healthcare professional recognises and utilises the resources available through colleagues and other organisations that can support patient health. (Medication) Transcribing Policy; version 2 Page 4 of 23

5 Contents Section Page 1 Introduction 6 2 Purpose 6 3 Definitions 6 4 Scope 7 5 Training and Competencies 7 6 Responsibilities and Duties 8 7 Transcribing Guidelines and Procedure 9 Who can Transcribe 10 Appropriate Situations to Transcribe 11 Appropriate Sources of information 12 Recording the Information 12 Responding to Errors 15 8 Monitoring Implementation 15 9 References Associated Documentation Appendices 1 Transcribing Flowchart Medicines Administration 17 Document 2 Transcribing Flowchart Record of Medicines 18 3 Example Transcriptions 19 (Medication) Transcribing Policy; version 2 Page 5 of 23

6 1. Introduction Transcribing is the act of copying medicines information, by someone who is not a qualified prescriber, which will be used to guide administration of medicine to an identified patient or the ongoing prescribing for the patient. The Nursing and Midwifery Council states that transcribing should only be undertaken in exceptional circumstances and should not be routine practice. 1 It is employed in Worcestershire Health and Care NHS Trust (WHCT) to minimise interruption to therapy, where a patient requires administration of a medicine, but it is not possible to gain timely access to a qualified prescriber to generate suitable Trust administration document, and the therapy was previously authorised by virtue of a prescription or direction to administer from an authorised prescriber, or in accordance with a patient group direction. 2. Purpose The policy is intended to provide clear guidance on the use of transcribing, where necessary, to minimise interruption to therapy, to describe the situations where transcribing can be used in WHCT, who can transcribe medicines information and to give an overview of the process for transcribing. Staff who wish to transcribe must successfully complete the associated training. 3. Definitions Transcribing: Any act by which medicinal products are written from one form of direction to administer to another; including, discharge letters, transfer letters, copying illegible patient administrations chart onto new charts (whether handwritten or computer-generated). 1 Transcription: Accurate copy of information. In this policy relates specifically to medicines information. Prescribing: The act of writing an instruction that authorises a patient to be issued with a medicine. Only an individual who holds an appropriate qualification that authorises him/her to prescribe (doctor, dentist, non-medical prescriber), and is approved to prescribe by the Trust, can prescribe. Prescription: An instruction that authorises a patient to be issued with a medicine or treatment. It can only be generated by an individual who holds an appropriate qualification (see Prescribing ). There are specific details that must be included to make the prescription legal. Direction to Administer: Details of therapy relating to a named medicine and named patient that provide clear instruction to administer that medicine to the patient. It differs from a prescription in that it might not contain the appropriate information to legally authorise issue of a supply of the medicine to the patient. Example: medicine entry on Inpatient Medicines Administration Chart is a direction to administer a medicine to a patient on a dose-by-dose basis, but does not include detail to authorise supply to the patient to take away from the unit. (Medication) Transcribing Policy; version 2 Page 6 of 23

7 4. Scope This policy applies to all staff and services involved in the administration of medicines and the handling of medicines regimen information, across WHCT, irrespective of where the patient resides. See Who can transcribe? for staff authorised to transcribe in WHCT. Only those deemed competent in-line with training can transcribe. 5. Training and Competencies Any staff member wishing to become a transcriber must meet the following criteria: i. Be registered with an appropriate professional body: ii. Manager and Service Lead must agree that it is appropriate to the needs of the service and the individual s role for them to train as a transcriber iii. The individual must have no fitness to practise concerns against them. iv. The individual must have read and be familiar with: a. This policy b. Medicines Policy v. The individual must have up-to-date successful completion of the following training,: a. All mandatory training b. Medicines Management c. Clinical Record Keeping If the criteria are met the individual can apply to train as a transcriber. Transcribing Training comprises: i. Theory taught element of training, via on-line learning or face-toface training. ii. Competency based test mock scenarios involving transcription of medicines information. Transcriptions must be completed accurately an in accordance with the policy. Both elements must be completed successfully for an individual to be approved to transcribe. Successful completion of training will be recorded on the individual s ESR. If this record is not present the individual must not transcribe. If the individual fails the competency-based training there may be an opportunity to take a resit test, depending on the nature of reasons for failure and on agreement of the manager/service lead. Renewal of Competency: i. The competency is valid for 3 years. Training must be repeated successfully within 3 years after the initial competency, otherwise the competency will lapse and the individual must not transcribe. ii. If an individual does not transcribe in practice for a period of one year then they must repeat and pass the competency training before transcribing again. The line manager must consider whether transcribing is appropriate to the individual s role. (Medication) Transcribing Policy; version 2 Page 7 of 23

8 6. Responsibilities and Duties Transcriber Ensure that all medicines details are accurate, appropriate and safe for the patient. The transcriber must only transcribe and enable administration of medicine where they are confident that this is the case. If the transcriber finds medicines information that is unclear or they believe to be inaccurate or unsafe they must not transcribe. If the transcriber finds medicines information that is unclear or they believe to be inaccurate or unsafe they must contact an appropriate prescriber and ensure resolution of the problem. Transcribe medicines details in-line with this policy, the Medicines Policy and other associated policies. Ensure that their training is up-to-date. Manager Read and fully understand the policy, how it relates to their service and be assured that application within their service complies with all clinical governance requirements. Ensure that staff have read and understood the policy. Ensure that the transcriber undertakes necessary training (and refresher training), in-line with this policy, and that this is recorded on the transcriber s ESR. Ensure time is made available for the individual to train. Take action, in-line with the appropriate policies, in response to errors relating to transcribing. Prescriber (including medical and non-medical prescribers) Countersign transcription as soon as practicable, to confirm the appropriateness of therapy and accuracy of the direction to administer. Pharmacist Review transcriptions, in-line with routine clinical practice, as with other medicines directions, ensuring that all transcriptions meet the additional requirements of this policy. Transcribe, where appropriate, in-line with this policy. Provide transcribing training, in-line with this policy. Staff member administering medicine The staff member administering medicine is responsible for their actions and must only administer when they are confident that it is safe and appropriate for them to do so. If the staff member finds a transcription that is unclear or they believe to be inaccurate or unsafe they must not administer the medicine. If the staff member finds a transcription that is unclear or they believe to be inaccurate or unsafe they must ensure resolution of the problem, by contacting an appropriate clinician, including the transcriber, a prescriber, nurse manager. Administer medicines in-line with the transcription, if safe and appropriate to do so. Administer medicines in-line with relevant policies and personal training and competencies. (Medication) Transcribing Policy; version 2 Page 8 of 23

9 General The Chief Executive of the Trust has overall responsibility for the safe and secure handling of medicines by staff employed by WHCT. The Medical Director is the Executive Director with responsibility for the safe and secure handling of medicines. The Chief Pharmacist is responsible for all actions regarding the safe and secure handling of medicines. The Operational Director has responsibility for ensuring employed staff are aware of, and implement the policy. Managers have a responsibility to ensure that access to the policy is made available to their staff and to ensure that their staff are fully aware of all drug administration procedures applicable to their ward/department. The Medicines Management and Safety Sub-Committee (MMSSC) is responsible for approving this policy prior to ratification by the Trust Quality and Safety Committee. It also has responsibilities for identifying new medicines risks and updating the policy accordingly. Individual staff remain responsible for their own actions and must only undertake administration of medicine if they are assured that it is safe and in the best interests of the patient. 7. Transcribing Guidelines and Procedure Transcribing is ANY act by which medicinal products are written from one form of direction to administer to another. In WHCT this includes creating a record that is intended to guide the development of a direction to administer or future prescribing Transcribing is not related to competence in a clinical field, but competence to generate an appropriate direction to administer. Transcribing can only take place for therapy already authorised in a prescription or inpatient direction to administer generated by a qualified prescriber. Transcribing cannot be used to initiate a new medicine, even on the direction of a prescriber. A prescription or direction to administer must already be in place for the transcriber to transcribe. The transcriber is not involved in making clinical decisions about the medicines regimen; the transcriber: o Must not make any changes to therapy, o Must not guess. If the source of information that the transcriber is using is unclear in any way then transcribing must not occur. o Must not transcribe anything they believe to be incorrect or unsafe. If the transcriber finds something that they believe to be wrong or unsafe or is unclear in therapy they must refer to an appropriate prescriber. There are no specific restrictions on transcribing a controlled drug, as the legal prescription must already have been generated. A prescriber (medical or non-medical) or transcriber must be confident that the prescription details they record are accurate and that the directions are safe and appropriate for administration of the medicine to the patient. (Medication) Transcribing Policy; version 2 Page 9 of 23

10 Some services work with healthcare assistants (HCA) who administer medicines against transcribed directions. The HCAs have received in-house training to administer medicines, but will have less training and experience with prescribed medicines information that a qualified nurse; therefore, there is the added requirement on a transcriber to clarify directions that include Latin and abbreviations. Medicines cannot be supplied to a patient to take home against a transcription. Medicines can only be issued to a patient against a prescription. If a patient was admitted to a service with a supply of their own medicines these remain the property of that patient (they were originally issued against a prescription) and can be returned to the patient on discharge, if appropriate (see Use of Patients Own Drugs Standard Operating Procedure). Recording information relating to the use of medicines in the clinical notes is part of expected routine clinical practice for a clinical professional. It does not constitute transcribing, unless that information is used to guide future prescribing or administration. Who can Transcribe Registered nurses. Nurses in WHCT can transcribe in-line with this policy, after successful completion of the associated training. Pharmacists. Pharmacist are authorised to transcribe medicines information by virtue of their pharmacy qualification. Non-medical prescribers (NMP). o Non-medical prescribers have a qualification that shows they are competent to appropriately record medicines information, but a prescription must be in-line with their Scope of Competence. o Where a medicine prescription falls outside of a NMP s Scope of Competence any rewrite should be regarded as transcribing. They do not need to undertake the transcribing competency training, but they must adhere to this policy with regard to transcribing the medicine details. o A transcription written by a non-medical prescriber may be interpreted as a prescription if not clearly annotated as a transcription the prescriber may be regarded as responsible for the clinical appropriateness of the therapy. o A NMP may choose to complete the transcribing competency training. Doctors. Any medicines prescription information written by a doctor is considered the responsibility of that doctor and they remain accountable. No other staff are permitted to transcribe. Transcribing must be undertaken by the service providing continuing care or accepting an admission, not by the service that is referring or discharging the patient. (Medication) Transcribing Policy; version 2 Page 10 of 23

11 Appropriate Situations to Transcribe Transcribing must not take place where an appropriately qualified and competent prescriber is available writing and rewriting prescription information is the responsibility of the prescriber. The NMC states that transcribing should only be undertaken in exceptional circumstances and should not be routine practice. 1 Transcribing medicines information may be appropriate in the following situations: a. Patient is newly admitted to the care of a team/unit and requires administration of a medicine before a prescriber will be available to write up an administration chart and no current appropriate administration chart is available to use. The clinical lead/manager may choose authorise the use of existing prescribing/administration charts transferred with the patient from another service (eg if discharged from a different NHS Trust) if these are clear and easy to use, whilst awaiting a qualified prescriber, rather than implement transcribing (see Appendix 1). b. Current prescribing/administration chart is unusable and the patient requires administration of a medicine before a prescriber will be available, eg chart has become damaged or illegible (see Appendix 1). c. The team/unit/service does not have access to a qualified prescriber, and the patient is admitted with a supply of their own medicines (see Appendix 1). The following situations must also be considered transcribing and only conducted by someone authorised as a transcriber, in-line with this policy: a. Creating a prompt chart a record for a patient or carer listing all medicines in one document. Approved Trust format must be used. b. Listing medicines therapy information in a discharge letter or care plan. Where it is more appropriate for another member of staff to record this information (eg Care Coordinator) then the section of care plan/letter etc where medicines information is recorded must be fully checked, confirmed and countersigned by a qualified prescriber (see Appendix 2). c. Transfer of faxed or ed prescription information to an administration chart that has been provided remotely by a qualified prescriber (see Medicines Policy Remote Prescriptions), ie prescriber provides written (typed/ ed/faxed) direction to administer (see Appendix 1). NMC requires transcriptions to be signed off by a registered prescriber. This should be done as soon as practicable. Where a service operates without access to any prescribers then the following conditions apply: o The service lead must complete a risk assessment on the use of transcribing. o The SDU Lead, in conjunction with the Clinical Lead and/or Quality Lead must approve use of transcribing in the service. (Medication) Transcribing Policy; version 2 Page 11 of 23

12 o Transcribing can only be used to guide the administration of patients own medicines. Stock medicines cannot be administered against transcribed directions in these services. Appropriate Sources of Information Refer to the Medicines Reconciliation Policy for guidance on how to collect and confirm details of current therapy. Only the following sources of information can be used to transcribe: a. Existing prescription. This can include a fax, photocopy, carbon copy or photo where all medicines and patent details and dates are clearly visible. b. Existing direction to administer (eg inpatient medicines chart). c. FP10 back page that lists current therapy and patient details. d. Actual medicines in dispensed and pharmacy-labelled bottles and boxes. Refer to Use of Patients Own Drugs Standard Operating Procedure for guidance on how to assess medicines and use the details on the dispensed labels. e. Medicines adherence aids/boxes (Dosett and related devices) that have been prepared by a pharmacy and are clearly labelled with up-to-date medicines and dose instructions. Note: Devices prepared by anyone else must not be used. See below (Recording the Information) for instructions on how to provide directions for administration from an adherence aid. f. Faxed or ed prescription/direction to administer. g. Current discharge prescription form, inc electronic discharge summary. h. Clinic letter clearly identifying the patient and medicines and regimens. i. Direct access to medical records, inc electronic systems. j. Summary Care Record. k. Printed record of medicines from GP records that clearly identifies the patient and current medicines and regimens. l. A transcription (that meets one of the above requirements) If discrepancies exist between different sources of information then transcribing and administration of medicines must not occur; guidance must be sought from an appropriate prescriber. Changes cannot be made to therapy based on information provided by the patient, a family member or carer. Any discrepancies must be clarified with the prescriber and confirmed in writing. Recording the Information Refer to the Medicines Policy for guidance on the approved way to record medicines information, including permitted abbreviations, cancellation of prescriptions, and the use of multiple charts, where necessary. Transcriptions must comply with the Medicines Policy. Transcriptions must be written in capital letters, in black, indelible ink, or typed. (Medication) Transcribing Policy; version 2 Page 12 of 23

13 The transcription must be created and signed by the same person (ie not written by one person and signed by someone else). A prescriber should countersign the transcription at the earliest opportunity. All patient details must be copied without change. The patient must be clearly identified, with a minimum of 3 pieces of data. Consider: o Name o Date of birth o NHS number o Address o Dispensed medicine labels only include patient name as an identifier; however these remain acceptable sources of medicines information for transcribing. It is expected that the transcriber will have access to other clinical information to confirm the identity of the patient. Where the clinician has concern over the ownership of a medicine (eg two patients with same name live at same address) then other source of information must be used to confirm therapy. The following details must be recorded: o Details of any allergies or intolerances (including nature of response) o Details of the medicine and regimen: Name. Generic name is usually preferred, but brand name may be more appropriate for modified release and compound preparations, or where the specific named brand must be maintained for clinical reasons. Write in capital letters. Formulation (eg tablets, capsules, solution etc). Strength (not necessarily the same as dose; particularly necessary for liquid preparations). Route (consider need to alter sites for some parenteral administration). Dose. If using medicines chart, write dose in against administration time and in detail box. Frequency of administration. Where the style of recording chart requires it write out the frequency in words and not figures eg THREE TIMES A DAY or THREE x DAILY and not 3 x daily. Administration time(s). If using a medicines chart, circle the most appropriate time(s) (or amend as necessary) and ensure the correct dose is written against each time. Name and location of original prescriber Dates: The transcriber must record a date against each transcription identifying the date on which the transcription is made. If a short-course of medicine is transcribed (eg antibiotic course) then the start date and stop date for the short course must also be clearly stated the transcriber will need to ascertain (Medication) Transcribing Policy; version 2 Page 13 of 23

14 the date on which the short-course was initiated. This might result in three dates being recorded against the transcription (start date of course, stop date of course and date of transcription). For long-acting preparations or medicines that are administered infrequently the transcriber must determine when the medicine is due, even if discharged date is predicted to be before the date of the required medicine. All medicine details must be copied without change, except for the following issues: o Abbreviations must be expanded explained. o Latin prescribing terms must be translated. o Prescriptions/directions where the format of details does not adhere to Medicines Policy must be rewritten to comply with the Medicines Policy, but the regimen must not be altered. o Interpretation of frequency: Where there is no specified clinical reason for administering a medicine at a specific time (eg with a meal) then multiple daily doses should be interpreted as having equal intervals, eg twice daily = a dose every 12 hours; three times a day = a dose every 8 hours. Antibiotics should always be administered with equal dose intervals to maintain the effective level of drug and reduce the risk of the development of antibiotic resistance. Once daily: clarification must be sought as to most appropriate time of day. The patient may be able to advise on when the medicine has been taken previously. When required / PRN: clarification must be obtained, from an appropriate prescriber, on the indication for use, dose interval, total daily dose. Other Ambiguities: As directed this is insufficient to enable transcription clarification must be obtained from an appropriate prescriber. Two daily this means two dose units (eg two tablets) taken at the same time once daily; it is not the same as one dose twice daily. The transcriber must not make any changes to the therapy. If transcribing for administration from an adherence aid/box Dosett etc), using one drug chart entry section, the transcriber should write Administer in-line with Adherence Aid. Administration times must reflect those provided in the adherence aid. Identity of Transcriber must be clearly recorded: o The transcriber must sign each medicines entry that will be used to directly administer medicines (eg medicines chart) or as appropriate in a care plan/letter. (Medication) Transcribing Policy; version 2 Page 14 of 23

15 o The transcriber must clearly print their name against each medicines entry that will be used to directly administer medicines (eg medicines chart) or as appropriate in a care plan/letter. o The transcriber must clearly identify that medicines details have been recorded by a transcriber by writing the word transcribed or transcriber against each entry that will be used to directly administer medicines (eg medicines chart) or as appropriate in a care plan/letter. o Contact details for a transcriber should be included to allow easy referral in case there is a query about a transcription. The transcriber should document the reason for transcribing and sources of information used in the patient s notes. Full consideration must be given to the abilities of every person who might need to refer to the transcription, including command of English, visual impairments, learning disabilities or cognitive impairments. In particular, consider how this might apply to adherence-prompt charts used by patients and carers. Refer to Accessibility (translation and interpretation) at the start of this document. Refer to Appendix 3 for Example Transcriptions Responding to Errors If a transcribing error is discovered, the transcription must be cancelled and it must not be used to administer medicines or to provide information to others. The transcriber, the transcriber s line manager and the prescriber must be informed of any error in transcribing. All transcribing errors must be recorded on Ulysses as: o Type of Incident: Medication; o Cause: Med Error - Documentation. Errors will be handled in line with the Managing Medication Error Policy Based on the nature of the transcribing error, the service lead must decide whether: o To inform other staff who will encounter transcriptions made by the individual. o To recall all active transcriptions made by the individual. o To remove authorisation for the individual to transcribe. o To refer the transcriber for early refresher training. Advice may be sought from the Pharmacy Team in these decisions. If a transcribing error has resulted in a medicines administration error the patient must be informed, in-line with the Being Open and Duty of Candour Policy. Follow the Managing Medication Error Policy. 8. Monitoring Implementation Training and retraining is delivered by the Department of Pharmacy and Medicines Management and recorded on ESR by the Training and Development Unit. It is the responsibility of the staff member s manager to (Medication) Transcribing Policy; version 2 Page 15 of 23

16 ensure that the staff member has the appropriate documented competency before authorising them to transcribe. Each ward/unit/service must develop a process for systematic assessment of transcribing practice that includes: i. A random sample of transcriptions assessed for accuracy and adherence to Medicines Policy, not less than annually. ii. Review of the extent of the use of transcribing and potential alternatives. This should be reviewed by each service lead not less than annually. iii. Review of the reasons that transcribing was necessary when used. It is recommended that managers/service leads seek input from colleagues outside of their own ward/unit/service, who are familiar with transcribing, when conducting assessment. Clinical pharmacists monitor the quality, accuracy and appropriateness of prescriptions and transcriptions as part of their routine practice. Errors and non-compliance with relevant polices will be notified to the transcriber s manager. 9. References 1. Nursing and Midwifery Council, NMC Standards for Medicines Management. Available at: <accessed 6/7/16>. 10. Associated Documentation Medicines Policy: Medicines Reconciliation Policy: Use of Patients Own Drugs Standard Operating Procedure: Self-Administration of Medicines Policy: Clinical Record Keeping Guidelines: Managing Medication Error Policy: Being Open and Duty of Candour Policy: Training materials are maintained by the Department of Pharmacy and Medicines Management. 11. Appendices 1. Transcribing Flowchart Medicines Administration Document 2. Transcribing Flowchart Record of Medicines 3. Example Transcriptions (Medication) Transcribing Policy; version 2 Page 16 of 23

17 Appendix 1: Transcribing Flowchart Medicines Administration Document (Medication) Transcribing Policy; version 2 Page 17 of 23

18 Appendix 2: Transcribing Flowchart Record of Medicines (Medication) Transcribing Policy; version 2 Page 18 of 23

19 Appendix 3: Example Transcriptions Regular Medicines Inpatient Medicines Administration Record: Medicine name in BLOCK CAPITALS Descriptive directions Route State each dose per time Date of administration Formulation Dose Include START and STOP dates for short courses 2016 CLARITHROMYCIN TABLETS 250mg TWICE DAILY ORAL 250mg 12/7/16 18/7/16 TRANSCRIBED 15/7/16 ANDY DOWN 250mg 20 15// X Signature of transcriber Date transcribed Name printed State Transcriber or Transcribed Circle of change time if necessary Cross through unnecessary boxes to prevent inappropriate administration Community Prescription and Administration Card: Medicine name in BLOCK CAPITALS Descriptive directions Can enter different doses at different times (also applies to inpatient chart) Formulation Route ORAL AMISULPRIDE TABLETS 200mg IN MORNING; 400mg AT NIGHT ANDY DOWN TRANSCRIBER 15/7/16 200mg 400mg 8am NIGHT 15 Signature of transcriber Name printed Date transcribed Use specific time or meaningful time, if appropriate State Transcriber or Transcribed (Medication) Transcribing Policy; version 2 Page 19 of 23

20 Appendix 3: Example Transcriptions When Required (PRN) Medicines Inpatient Medicines Administration Record: Medicine name in BLOCK CAPITALS Formulation(s) Dose per route Guidance on WHY to give a dose Route 5mg 3mg HALOPERIDOL (CAPS/INJ) ORAL IM THREE doses by any route ANDY DOWN 15/7/16 TRANSCRIBED Severe agitation THREE doses per day THREE doses per day Guidance on HOW to give dose Signature of transcriber Number of doses permitted in 24hr Name printed State Transcribed or Transcriber Community Prescription and Administration Card: Date transcribed Medicine name in BLOCK CAPITALS Guidance on HOW to give dose Route Single, clear dose Guidance on WHY to give a dose PARACETAMOL TABLETS 1g ORAL Every 4-6 Hours PAIN MAX 4 DOSES ANDY DOWN TRANSCRIBED 15/7/16 Formulation Signature of transcriber Name printed State Transcribed or Transcriber Date transcribed Number of doses permitted in 24hr For examples or advice regarding transcribing in other situations contact the Pharmacy Team: Telephone: WHCNHS.medicines@nhs.net Intranet microsite: Pharmacy Services (Medication) Transcribing Policy; version 2 Page 20 of 23

21 Equality Analysis Equality Analysis Worcestershire Health & Care NHS Trust (WHCT) has a responsibility under the Equality Duty to: (1) eliminate discrimination; (2) advance equality of opportunity and (3) foster good relations with regarding to age; disability, gender reassignment, pregnancy & maternity; race; religion or belief; sex; sexual orientation or marriage and civil partnership, the 9 protected characteristics defined by The Equality Act 2010 (See Appendix 1). Equality Analysis is a way of identifying any potential or actual impact (Positive, Neutral or Negative) that our policies/functions (functions include; Services; Projects; Strategy; Processes; Systems; Practices; Procedures; Protocols; Guidelines; Care Pathways etc..) and their implementation many have on differing groups of people. An Equality Analysis must be undertake for all new and existing policies and functions to ensure a fair service for all. The purpose of the Equality Analysis is to: make us focus on the needs, experiences and circumstances of everyone who will be affected by the decisions the Trust makes direct us to seek alternative ways of achieving our aims and avoiding inequality enhance our creditability with our service users to have greater confidence in our performance improve our policy making procedures and services make use more accountable in the relationships When completing the Equality Analysis you are encouraged to consider the impact the policy/function may have on the protected characteristics and persons/groups who do not share these characteristics but could experience inequality e.g. carers, the homeless or travelling communities and record the evidence to demonstrate the consideration given. Positive Neutral has a positive impact on one or more of the protected characteristics, improves or promotes equality has similar or no impact on the protected characteristics Negative disadvantages or has an adverse impact on one or more of the protected characteristics Where the policy/function involves patients/careers/staff/partners/stakeholders etc, please include them in the Equality Analysis to demonstrate openness, transparency and inclusion and particularly by those who this policy/function is most likely to have impact. The Analysis is to be conducted by three assessors who determine the level of impact the policy/function has as follows: Low The policy/function has limited relevance to the Equality Duty Medium There is some concern or evidence available that different groups may be affected differently. The policy/function may be relevant to parts or all of the Equality Duty High There is evidence/concern to suggest different groups are affected differently. The policy/function is relevant to the Equality Duty. If the relevance is Low or Medium and the assessors are able to justify and demonstrate their reasons, these should be record on the primary Equality Analysis. If the relevance is High, where there is potential or actual discrimination it will be necessary to complete an advanced Equality Analysis, please contact the Equality and Inclusion Practitioner for advice and a copy of the advanced Equality Analysis (Medication) Transcribing Policy; version 2 Page 21 of 23

22 Equality Analysis Equality Analysis Title of Policy/Function (Function Includes: Services; Projects; Strategy; Processes; Systems; Practices; Procedures; Protocols; Guidelines; Care Pathways etc..) (Medication) Transcribing Policy New Existing/Revised Revised Short description of Policy/Function (aims and objectives, is the policy/function aimed at a particular group if so what is the intended benefit): The policy is intended to provide clear guidance on the use of transcribing, where necessary, to minimise interruption to therapy, to describe the situations where transcribing can be used in WHCT, who can transcribe medicines information and to give an overview of the process for transcribing. Staff who wish to transcribe must successfully complete the associated training. Name of Lead/Author(s) Job Title Contact details Andrew Down Deputy Chief Pharmacist andrewdown@nhs.net When the policy/function involves patients/staff/partners/stakeholders etc please where possible include them in the Equality Analysis to demonstrate openness, transparency and inclusion and particularly by those who this policy/function is most likely to have impact. Does this Policy/Function have any potential or actual impact that is positive(+), neutral (N) or negative (-) impact on the following protected characteristics please indicate: + N - Please provide a rational/justification for each of the following regardless of impact Age Age does not influence the application of the policy. Disability Visual impairments and dyslexia have the potential to influence the ability to read and write information, which is fundamental to the policy, but this is a broader consideration for the individual s ability to safely handle medicines and medicines information; it is not specific to the policy. Gender Reassignment Gender reassignment does not influence the application of the policy. Pregnancy & Maternity Pregnancy/maternity does not influence the application of the policy Race Language barriers, where English is not a staff member s first language have the potential to influence the ability to read and write information, which is fundamental to the policy, but this is a broader consideration for the individual s ability to safely handle medicines and medicines information; it is not specific (Medication) Transcribing Policy; version 2 Page 22 of 23

23 Equality Analysis to the policy. Otherwise, race does not influence the application of the policy. Religion & Belief Religion/belief does not influence the application of the policy. Sex Gender does not influence the application of the policy. Sexual orientation Sexual orientation does not influence the application of the policy. Marriage & Civil Relationship status does not influence the application Partnership of the policy. Other Groups who could experience inequality, eg carers, homeless, travelling communities, unemployed, people resident within deprived areas, different socio/economic groups eg low income families, asylum seekers/refugees, prisoners, people confined to closed institutions or community offenders, people with different work patterns eg part-time, full-time, job-share, short-term contractors or shift workers - Access, location and choice of venue, timings of events and activities. Support with caring responsibilities The ability to transcribe within WHCT is limited to specific staff groups with specific qualifications; other staff are not permitted to transcribe. Analysis conducted by: (minimum of 3 people) Name Job Title Contact details 1 Andrew Down Deputy Chief Pharmacist andrewdown@nhs.net 2 Carole Roberson Lead for corporate nursing ( community services) 3 Shelley Priest Senior Pharmacist Medicines Safety Start date of policy/function 15/09/16 Period valid for : 3 years Review date of policy/function 15/03/19 c.roberson@nhs.net shelley.priest@nhs.net Service Delivery Unit: Reference/Version: MED-037 version 2 Date Equality Analysis completed: D D M M Y Y If you have identified a potential discriminatory impact on the policy/function please refer it to the author together with suggestions to avoid or reduce the impact. A copy of the completed Equality Analysis must be attached to the policy/function and a copy sent to: Patrick McCloskey Equality Inclusion Practitioner Isaac Maddox House, Shrub Hill Road, Worcester, WR4 9RW Tel: patrick.mccloskey@nhs.net (Medication) Transcribing Policy; version 2 Page 23 of 23