Final answer:
When prescribing or dispensing drugs, documentation in the patient's file should include the patient's name and age, the drug name, dosage, route, date of prescription, and prescriber's signature and contact information. Pharmacists, with their extensive background in chemistry and biology, ensure proper medication use and play a critical role in this process.
Step-by-step explanation:
When drugs are prescribed/dispensed, it is important that certain information be accurately documented in the patient's file for safety, legal, and medical reasons. The documentation must include, at minimum:
- Patient's name and age to ensure that the prescription corresponds to the correct individual.
- The drug name, dosage, and route of administration to detail what medication the patient will be taking and how it is to be used.
- The date of prescription to track when the medication was ordered and for how long it should be taken.
- Veterinarian's signature and contact information, if applicable, to verify the authority of the prescription and to provide a point of contact for queries or concerns regarding the medication.
For procedures involving anesthesia or surgery, the nurse also reviews items such as the name of the procedure recorded, counts of needles, sponges, and instruments, and labels on specimens. In the context of patient-safe practices, this is also critical information that may be recorded in patient files.
Pharmacists play a key role in the process of dispensing medication. In the United States, they require a doctorate in pharmacy and must be licensed to work. Their educational background in chemistry and biology equips them to understand how drugs, which are essentially chemicals, interact with the body. They help ensure proper medication use by advising on selection, dosage, interactions, and side effects.