🗒 Prescribing - If it's not in the notes, it didn't happen

Prescribing concerns for a Coroner

This should be the motto by which you run your practice and as healthcare practitioners, we should be mindful of this at all times when creating patient records. If required, it will form the basis for explaining your management and it is of course much easier to refer to your contemporaneous notes than attempting to answer challenging questions in court with the words, "from my recollection". AHPRA and the coroner will not look favourably on poor quality medical records. It is an interesting exercise for each of us to refer to the most recent entries in the notes for some of our patients for example, those who have significant mental illness or who are taking long term opiates or benzodiazepines, to see if weare happy with how they would appear to the coroner.

Some issues that will prompt questions from the Coroner

Inappropriate prescribing 

A patient was prescribed ampoules or morphine for self-administration for migraine.

Lack of awareness/communication of the potential for toxicity when prescribing  

A patient prescribed 80 x propranolol tablets for anxiety symptoms. She took 30 tablets at once and soon began feeling unwell. She called a friend admitting it was a "cry for help" and "I don’t want to die", but was dead by the time the paramedics arrived.

Failing to consider or check for evidence of drug seeking behaviour

A call to the ‘doctor shopper’ line would have revealed the patient had 3 other prescribers of OxyContin and diazepam over the preceding 3 months, totalling 300 hundred tablets, but claimed to be taking only on an ‘as required basis’ once or twice a week. A prescription was issued and the patient was found dead with a suicide note having stockpiled medication.

Prescribing Schedule 8 medicines without a valid permit  

A patient presents with a request for methadone tablets for chronic back pain (as evidenced by a letter from the pain clinic). The GP knows he is unable to prescribe methadone liquid for opiate substitution but after further investigation satisfies himself he can prescribe tablets for this indication. He issued the prescription and the patient is found dead in her bed the next day. A GP in another clinic held a schedule 8 permit, so the prescription was issued illegally. 

Prescribing outside of licensed indications 

There are many situations when medication is prescribed ‘off license’. However, the onus is on the prescriber to defend their prescription if a patient comes to harm from an off-label prescription. It is common practice for antipsychotic medication to be prescribed as sedatives and anxiolytics in the absence of psychotic illness. This is outside of the licensed indications, and if prescribed on PBS is also not fulfilling Medicare requirements. For example, Xanax, now schedule 8, is licensed for ‘short term use’ of anxiety. Consideration should be given when issuing long term prescriptions for such medications. 

As a practitioner it is important to document a risk assessment when dealing with patients with mental health issues. This is difficult in reality as often a suicide is ‘out of the blue’. However, when a patient presents with a change in mental state or when medication is altered it is important to record that consideration has been given to a risk assessment. It is difficult to describe your risk assessment retrospectively when the only entry in the notes on the last consultation was "anxious and depressed, Rx issued".   

Document a follow-up plan, eg arranging a review appointment with a patient a week after initiation of antidepressants. If they fail to attend this appointment you then have an opportunity to follow up and call and check on their well-being. 

Further reading

Australian Prescriber magazine - Off label prescribing

Weekend leave and involuntary detention under the Mental Health Act: can a hospital be held liable for a patient self-harming whilst on weekend leave?

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