Legally, whatever you have written is everything, not whatever you have done. So the prescription should be written in such a way that it become the most powerful defence for you. It is important to treat each and every prescription as a potential source of litigation. In my opinion, it’s to be thorough and honest, although will be a bit time consuming indeed. But the amount of extra time is worth investing for self defence.
My suggested check list:
Initial note: general consent, name and relationship of accompanying person, whether patient is not seen/only reports reviewed, visit no. (whether follow-up or first visit)
History: presenting complaints, co-morbidities, relevant past history, ADDICTION history, ALLERGY history, higher mental status, other relevant information related to present context.
Vitals: Body weight, pulse, BP, febrile or not, tachypnea/bradypnea, other relevant ones.
Systematic examination: relevant positive and important negative findings.
Previous investigation reports: brief note of relevant ones
On going medications – including non-prescription/self prescribed/ homeopathic/ ayush medications
Provisional and differential diagnosis, in order of probability
Investigations advise: check that they cover to rule-in or to rule-out all the D/Da, don’t mention the name or pH no. of diagnostic centre/contact person on prescription, write any pre-investigation instructions if there is any (e.g. after 12 hours fasting/early morning clean mid-catch urine etc.)
Medicines: write claerly and legibly: Name (GENERIC followed by brand within parentheses), dose, frequency with timing, route, before/after food, any special instructions (e.g. dissolved in a glass of water/start antibiotics after sending urine for C/S etc.). For SOS medications: indication, maximum dose per day, maximum number of days.
Surgery/intervention: name, type of anaesthesia, brief summary of procedure, whether PAC/cardiac/ respiratory/ neuro/nephrology clearance is required, tentative date and time (if possible) and RISK grade and nature (cardio vascular/respiratory/anaesthetic etc), and important preoperative instructions.
Diet: brief outline
Others: e.g. weight loss counseling done, CPAP use explained, home CBG monitoring timings and target sugar levels, symptoms and management of hypoglycemia explained etc.
Note: to get hospitalsed/inform if (warning signs)
Check: the medications have covered all possible D/Ds and co-morbidities, no serious interacting medications are given together, no banned/non-approved/irrational combination, no unnecessary drug of doubtful indication, drug formula and dosage is consistent with renal profile, hepatic profile, age, body weight, lactating/pregnancy status, electrolyte levels.
Note at the bottom: current clinical status of the patient, possible course of illness if not treated versus if treated, treatment options and risks and benefits of all, proposed line of clinical care, and expected outcome (‘___’ prognosis) were explained to the patient and his/her relative (name, relationship) in their own language and at level of their understanding, that they understood clearly and agreed with the proposed treatment plan.
Sign, date, time
Countersign: patient/relative with date, time
Please comment if there is any omission.
If we make a format and get it ratified by a medico-legal expert, it may be less time consuming.