T2.13 Prescription Writing & Regulations – Midwifery Lecture Notes

Overview of Prescription Methods

Midwifery prescribers must be able to issue both paper and electronic prescriptions.
Pre-COVID: majority of prescriptions were paper, handed, faxed or posted → caused delay & privacy issues.
Since COVID-19: rapid roll-out of electronic prescriptions (e-scripts) endorsed by Te Whatu Ora │ Health NZ.
- 22 Dec 2022 amendment to Misuse of Drugs Regulations 1977 allows signature-exempt e-scripts for controlled drugs provided secure identifier (barcode/ID code) is present.
- Faxing being actively phased out for safety & confidentiality.

Medicines Regulations 1984 – regulation 41(7) & 84 dictate minimum information, legibility, and signature/unique identifier requirements.
Misuse of Drugs Regulations 1977 – governs controlled drug prescription process & offences (fine up to $500 for breaches).
Primary Maternity Services Notice 2021 (Clause CB1.13, p.29) – spells out documentation requirements for midwifery prescriptions.
Duty to supply information: Medical Officer of Health may demand justification data within 30 days if improper prescribing suspected.
Practitioner Supply Orders (PSO) audited across pharmacies; fraudulent/misused PSOs trigger disciplinary action via Midwifery Council.

Header must contain:
- Prescriber’s full name.
- Physical street address (NO PO Box).
- Phone number for queries.
- Midwifery Council registration number.
Left-hand tick/circle codes identify patient & subsidy status:
- Age codes: A Adult (≥18 y), J Junior (13-17 y), Y Young person (<13 y), O Oral Contraceptive.
- Funding codes: 1 CSC holder, 2 midwife-only subsidy, 3 no CSC & non-eligible prescriber, 4 High-Use Card.
- Always circle A + 4 for standard adult midwifery script.
Client details:
- Full name, address.
- If ≤13 y old, record date of birth.
Medication section (three discrete boxes):
- One medicine per box — never combine drugs.
- Spell medicine & strength in full (avoid abbreviations: write micrograms, milligrams etc.).
- Include route, dose, frequency, duration.
- Quantity column: write period of supply, e.g. {3/7} not “3” or “28 caps”.
- Draw diagonal line through unused space & blank quantity boxes to prevent tampering.
Prescriber signature & date at bottom.

Security:
- Unique barcode/identifier substitutes for wet signature.
- Prescriber can use re-print function to correct or resend.
System blocks items outside midwifery scope (e.g., benzodiazepines) → safety feature.
Observed benefits: speed, legibility, automatic inclusion of prescriber details, reduced transcription error.

Quantity written as period supply \text{days/7} (e.g. 5/7) rather than tablet count.
Example: Mastitis in penicillin-tolerant patient
- “Flucloxacillin 500\,\text{mg} PO q6h for 7 days”
- Pharmacist calculates 4\times7=28 caps.
- 10-day courses no longer first-line due to antimicrobial-resistance stewardship.
Trimethoprim cystitis example (correct format):
- “Trimethoprim 300\,\text{mg} tablet PO nocte for 3/7.”
Max legal supply per script (authorised prescriber):
- Oral contraceptives: ≤6 months.
- All other Rx meds: ≤3 months.
- Vitamins/iron (iodine \;150\,\mu g, iron, vit D) often issued for 3 months—but consider post-partum scope (4-6 weeks) & inform GP if course extends beyond discharge.

Historically allowed with follow-up hard copy within 7 days.
Electronic era: 7-day rule waived; prescriber expected to send e-script ASAP.
Still relevant for remote areas still using paper or after-hours emergencies.
Build relationships with local pharmacists so they will safely dispense on verbal order when birth attendance prevents immediate e-script.

Prior discussion of indications, benefits, alternative treatments, side-effects, risks → informed consent.
Provide written leaflet: NZ Formulary printable hand-outs.
Document rationale & education in clinical notes.

Record:
- Diagnosis & indication for each prescribed medication.
- Discussion/consent summary.
- Alternative strategies attempted or considered.
Excessive or repeated prescription errors trigger pharmacist reporting → Midwifery Council.

Paper charts still common; Counties Manukau uses “MedChart” electronic MAR.
Students may:
- Document & co-sign oral/sub-cut meds under RN/RM countersignature.
- MUST NOT sign for controlled drugs or initiate/adjust IV infusions/epidural pumps without certification.
Legibility rules: black ink, block capitals, no ambiguous abbreviations.

Students:
- Can prepare IV fluids/lines they are signed off for, but cannot connect epidural catheters or manage epidural infusions.
- May adjust syntocinon ONLY under direct instruction; if fetal distress/bradycardia occurs, may stop infusion and call for help.
Registered midwives require additional accredited training before handling epidural infusions; same restriction applies to students.

Excessive prescribing (e.g., giving 3-month paracetamol for acute mastitis) may be judged unreasonable.
Condoms: Pharmaceutical Schedule lists maximum subsidised amount per 3 months (≈144 units) but midwife can issue smaller practical quantity (e.g., 24–36) and document rationale.
Non-compliance with regulations may lead to:
- Summary conviction ≤\$500 fine.
- Investigation by Midwifery Council.
- Mandatory cooperation with Medical Officer of Health.

Use NZ Formulary or NZF4L (pregnancy/lactation) to double-check dose/strength; never guess.
Always preview partner midwives’ e-scripts to learn format & system prompts.
On first LMC meeting explain cover arrangements for leave; clarify who can prescribe when lead midwife unavailable.
Visit local pharmacies; introduce yourself, share contact details, discuss after-hours procedures.
For controlled drugs, ensure dual sign-in/out and stock counts during each shift hand-over.
Maintain professionalism: complete prescription correctly the first time to avoid client frustration & lost time.