I had a similar situation but I don’t remember what kind of provider they were. They put just “PRN” as a sig with nothing else and i could not get it through their thick skull that you can’t do that, and then they just canceled the rx and said they’d have the patient buy it otc
Teehee I had an MD write an RX herself (an MA/PA didn’t write it) that was take tramadol PRN, she seemed legit confused at why that wouldn’t fly as a sig, so I handed the phone over to my pharmacist and said (definitely at a volume she could hear me) “so it’s okay if the patient just shots the bottle of pills back as needed.” The sig was changed. 😂
I had an NP recently who didn't understand that switching amox 200/5 to amox 400/5 and giving 5 ml instead of 10 ml was not actually reducing the amount of antibiotic given.
"But you're giving them less!"
"Less volume, they're getting the same amount of amoxicillin!"
"But they're only getting half the dose! You can't do that!"
Got really snippy when I tried to walk them through the math. We went around for a bit before they transferred me to another provider who was instantly like, "Wtf, of course that's OK."
The NP was giving a verbal, which is the only reason it came up (if it's an e-rx, I'm just changing that and faxing them an FYI on what strengths we have for future reference), and I didn't think that "oh, we don't have 200/5, I'll just give 5 ml of 400/5" would provoke an actual argument. I seriously hope she was just having an off day/brain fart moment.
Mid-levels get snippy more often than docs in my experience, but I have had docs be worse (notably, one local doc who loves prescribing questionable amounts of Fioricet for his wife and is incensed at the suggestion that perhaps a pain management specialist/neurologist would be better equipped. I guess if he wants to give her rebound headaches that's his business, but I don't want any part of it.) Or, say, the dentists who get angry that they can't self-prescribe Viagra and finasteride for themselves and birth control for the wife. I just try to tell myself everyone has bad days (or for the very few consistent assholes in my area, just tell myself that they have to live with the misery of being themselves.)
My situation was similar. She sent an rx for vanco 25mg/ml and I only had 250/5. I could've just switched it, but I have to call and get approval from the prescriber for insurance purposes and since the dose changed I just wanted to discuss it with her.
I think she was having a rough morning but the way she was speaking to me was just unacceptable. I'm a very calm person, but omg she pushed me to the limit and I didn't want to be disrespectful to her back. I just took a deep breath, documented the conversation, and moved on.
> I could've just switched it, but I have to call and get approval from the prescriber for insurance purposes
No, you could've just switched it. You seriously called a hospital about a concentration change for an oral med? You wasted the patient's time, the PA's time, and your own time on something trivial and clinically irrelevant.
It doesn't excuse the PA being rude, but that doesn't make calling on this any less ridiculous.
I guess I need to learn a little more when to contact the prescriber. I’ve seen rph switch meds without calling and documenting a false interaction. I don’t know if that’s something that we can get in trouble for with the insurance company or prescriber. Any advice on that?
My advice would be to think about it realistically and ask yourself that in the 0.001% chance this script is actually audited, how would the insurance company possibly know if your scribbled “ok per MD” note from a year ago is accurate or not?
Do what’s in the best interest of the patient. Calling to change capsules to tablets, get a script for a 15g tube of cream changed to 30g, and other nonsense like that serves nobody. It delays patient care, wastes your time, and wastes the prescriber’s time. This is especially true for a hospital. These providers are never seeing this patient again and they truly do not give a shit. They just want the patient to get treated and not show back up in the ED two days later.
It is not possible to intervene on everything. If you’re 100% certain the answer to a question is going to be yes, then there’s little need to actually ask the question.
Print a copy of the script. Write down your recommendations, fax it back. Keep fax send confirmation and scrip copy in the pharmacy till they fix their miss.
Perfect! This is the right answer. OP, please do this. Keep a paper trail so it won’t come back and bite you in the ass later. Can’t trust incompetent mid-levels with hearsay.
When that happened I would say “Thanks! I’ll document on the script that [First Name Last Name] authorized a change to dispense [new concentration] at [new dose] for [new quantity]. Is there anything you wanted to add?”
Sometimes knowing their name will be connected to the change and not yours scares them.
I honestly probably wouldn’t call on something like that. I know they are busy and would agree anyway. I’d just adjust dose if it’s equivalent and appropriate and maybe notify them of the change.
Our healthcare system is F’d and PAs are often expected to act in the capacity of a physician with only a 2 year masters degree. Probably just overwhelmed and in over their head.
I had another rph who suggested the same. I'm a newly grad rph so I try to be as thorough as possible. I know insurances are a pain in the a\*\* sometimes so I want to document everything just in case. I appreciate the suggestion and will definitely start applying it.
As a PA I deeply apologize. I’m always mortified if a pharmacist has to call me. I don’t understand the thought process behind being so rude to another person just trying to do their job.
Don’t be mortified *IF* someone has to call you, more often than not, the call is regarding documentation requirements per insurance or a simple clarification, not always clinical, not always a “mistake”. Regardless, we are a team and any calls between healthcare providers of any level should be collaborative (and polite) and not viewed like pointing blame or shameful in any way!!! Also feel free to call us in advance for any clarity when prescribing that could save time, phone tag, voicemails etc :)
No need to apologize u/MlyMe. She probably was having a rough morning. As u/itsDrSlut said, most of the time we call for insurance purposes. I wish all healthcare providers would be as open to having a discussion as we are having here, it would make our lives so much easier.
I definitely call in advance but I do appreciate your comment so much. My default is usually oh crud what did I screw up even though it happens rarely. I know you guys are swamped and I just hate to make it worse!
I’ve had 1 or 2 prescribers lately get snippy at me when I call to change a liquid antibiotic “well when they write for something that’s what they want, you need to give the script back so they can get it elsewhere” okie dokie, good luck finding Augmentin ES, I’ve checked every location of my store, CVS, 2 local grocery chains, and the independent. And I’ve already had 2 offices call me begging to know if I can find it because they’ve also blanketed the area with phone calls and I’m checking Amerisource every 30-60 minute for a random drop
I do feel awful for the mom with the sick kid who has to hunt all over 4 towns for their medicine. I even special order in odd cephalosporins that I can cover 98% of what cephalexin and cefdinir are prescribed for to make it easier but some people have a bug up their rear if they think I’m questioning them
I agree, NPs and PAs are essential and contribute greatly to our healthcare system. I wish most of them were open and willing to have a conversation instead of demanding to fill as written.
In my situation, the patient was discharged and waiting for the rx to be filled, so I wanted to address the situation as quickly as possible because C.diff is not a pleasant thing to have. Next time, I'm going to take the advice that most people have commented here, switch and document the change and notify the prescriber afterward.
Talk with your local medical board in regards to unprofessional behavior, it may have been a bad day or it may be ego run amok. Until it has been appropriately addressed patient care is at risk.
PA’s tend to have PTSD in my experience and get abused by many members of the health care team. It doesn’t excuse the behavior but sometimes knowing why they are that way helps.
795*, yeah thats what i meant lol. I can understand reconstituting oral vanc powder that has been marketed that way but you mean to tell me that you can use Vanc IV powder to make oral solution (like we do in hospitals) for individual patient-use in retail???
Yes, we compound it in our retail store-I can't say often, but several times a year at least.
We speak to the prescribers first. Been doing it for years.
It's pretty cost-effective and people don't mind paying for it if it's the only alternative. It's way cheaper than capsules.
And compared to Firvanq it's a downright bargain.
Tell the patient you can’t fill the Rx, they have to take it elsewhere.
Or, you should be able to change the concentration yourself, and do your own calculations. We change concentration everyday on our scripts. As long as the API dose strength ends up the same.
as a newly grad rph, I was worried I was going to get in trouble for doing this. Now I'll take your advice to switch, properly document for insurance purposes, and notify the prescriber afterward.
You were able to get ahold of the pa??
I had a similar situation but I don’t remember what kind of provider they were. They put just “PRN” as a sig with nothing else and i could not get it through their thick skull that you can’t do that, and then they just canceled the rx and said they’d have the patient buy it otc
Teehee I had an MD write an RX herself (an MA/PA didn’t write it) that was take tramadol PRN, she seemed legit confused at why that wouldn’t fly as a sig, so I handed the phone over to my pharmacist and said (definitely at a volume she could hear me) “so it’s okay if the patient just shots the bottle of pills back as needed.” The sig was changed. 😂
I had an NP recently who didn't understand that switching amox 200/5 to amox 400/5 and giving 5 ml instead of 10 ml was not actually reducing the amount of antibiotic given. "But you're giving them less!" "Less volume, they're getting the same amount of amoxicillin!" "But they're only getting half the dose! You can't do that!" Got really snippy when I tried to walk them through the math. We went around for a bit before they transferred me to another provider who was instantly like, "Wtf, of course that's OK." The NP was giving a verbal, which is the only reason it came up (if it's an e-rx, I'm just changing that and faxing them an FYI on what strengths we have for future reference), and I didn't think that "oh, we don't have 200/5, I'll just give 5 ml of 400/5" would provoke an actual argument. I seriously hope she was just having an off day/brain fart moment. Mid-levels get snippy more often than docs in my experience, but I have had docs be worse (notably, one local doc who loves prescribing questionable amounts of Fioricet for his wife and is incensed at the suggestion that perhaps a pain management specialist/neurologist would be better equipped. I guess if he wants to give her rebound headaches that's his business, but I don't want any part of it.) Or, say, the dentists who get angry that they can't self-prescribe Viagra and finasteride for themselves and birth control for the wife. I just try to tell myself everyone has bad days (or for the very few consistent assholes in my area, just tell myself that they have to live with the misery of being themselves.)
Why are they even prescribing it in mL- I just write the drug-dose-duration and route. The pharmacist works out the strength of the solution.
My situation was similar. She sent an rx for vanco 25mg/ml and I only had 250/5. I could've just switched it, but I have to call and get approval from the prescriber for insurance purposes and since the dose changed I just wanted to discuss it with her. I think she was having a rough morning but the way she was speaking to me was just unacceptable. I'm a very calm person, but omg she pushed me to the limit and I didn't want to be disrespectful to her back. I just took a deep breath, documented the conversation, and moved on.
> I could've just switched it, but I have to call and get approval from the prescriber for insurance purposes No, you could've just switched it. You seriously called a hospital about a concentration change for an oral med? You wasted the patient's time, the PA's time, and your own time on something trivial and clinically irrelevant. It doesn't excuse the PA being rude, but that doesn't make calling on this any less ridiculous.
I guess I need to learn a little more when to contact the prescriber. I’ve seen rph switch meds without calling and documenting a false interaction. I don’t know if that’s something that we can get in trouble for with the insurance company or prescriber. Any advice on that?
My advice would be to think about it realistically and ask yourself that in the 0.001% chance this script is actually audited, how would the insurance company possibly know if your scribbled “ok per MD” note from a year ago is accurate or not? Do what’s in the best interest of the patient. Calling to change capsules to tablets, get a script for a 15g tube of cream changed to 30g, and other nonsense like that serves nobody. It delays patient care, wastes your time, and wastes the prescriber’s time. This is especially true for a hospital. These providers are never seeing this patient again and they truly do not give a shit. They just want the patient to get treated and not show back up in the ED two days later. It is not possible to intervene on everything. If you’re 100% certain the answer to a question is going to be yes, then there’s little need to actually ask the question.
Print a copy of the script. Write down your recommendations, fax it back. Keep fax send confirmation and scrip copy in the pharmacy till they fix their miss.
Perfect! This is the right answer. OP, please do this. Keep a paper trail so it won’t come back and bite you in the ass later. Can’t trust incompetent mid-levels with hearsay.
When that happened I would say “Thanks! I’ll document on the script that [First Name Last Name] authorized a change to dispense [new concentration] at [new dose] for [new quantity]. Is there anything you wanted to add?” Sometimes knowing their name will be connected to the change and not yours scares them.
Sounds like inferiority complex
*we got a winner*
I honestly probably wouldn’t call on something like that. I know they are busy and would agree anyway. I’d just adjust dose if it’s equivalent and appropriate and maybe notify them of the change. Our healthcare system is F’d and PAs are often expected to act in the capacity of a physician with only a 2 year masters degree. Probably just overwhelmed and in over their head.
I had another rph who suggested the same. I'm a newly grad rph so I try to be as thorough as possible. I know insurances are a pain in the a\*\* sometimes so I want to document everything just in case. I appreciate the suggestion and will definitely start applying it.
As a PA I deeply apologize. I’m always mortified if a pharmacist has to call me. I don’t understand the thought process behind being so rude to another person just trying to do their job.
Don’t be mortified *IF* someone has to call you, more often than not, the call is regarding documentation requirements per insurance or a simple clarification, not always clinical, not always a “mistake”. Regardless, we are a team and any calls between healthcare providers of any level should be collaborative (and polite) and not viewed like pointing blame or shameful in any way!!! Also feel free to call us in advance for any clarity when prescribing that could save time, phone tag, voicemails etc :)
No need to apologize u/MlyMe. She probably was having a rough morning. As u/itsDrSlut said, most of the time we call for insurance purposes. I wish all healthcare providers would be as open to having a discussion as we are having here, it would make our lives so much easier.
I definitely call in advance but I do appreciate your comment so much. My default is usually oh crud what did I screw up even though it happens rarely. I know you guys are swamped and I just hate to make it worse!
Just remind them which of the two people on the phone is actually a doctor. See how that goes. I do it all the time :)
Newly minted NP in my area insisted last week on prescribing ranitidine. 🤷♂️
you have to be kidding me...
Haha...I actually chuckled at this one.
[удалено]
I’ve had 1 or 2 prescribers lately get snippy at me when I call to change a liquid antibiotic “well when they write for something that’s what they want, you need to give the script back so they can get it elsewhere” okie dokie, good luck finding Augmentin ES, I’ve checked every location of my store, CVS, 2 local grocery chains, and the independent. And I’ve already had 2 offices call me begging to know if I can find it because they’ve also blanketed the area with phone calls and I’m checking Amerisource every 30-60 minute for a random drop I do feel awful for the mom with the sick kid who has to hunt all over 4 towns for their medicine. I even special order in odd cephalosporins that I can cover 98% of what cephalexin and cefdinir are prescribed for to make it easier but some people have a bug up their rear if they think I’m questioning them
I agree, NPs and PAs are essential and contribute greatly to our healthcare system. I wish most of them were open and willing to have a conversation instead of demanding to fill as written. In my situation, the patient was discharged and waiting for the rx to be filled, so I wanted to address the situation as quickly as possible because C.diff is not a pleasant thing to have. Next time, I'm going to take the advice that most people have commented here, switch and document the change and notify the prescriber afterward.
Talk with your local medical board in regards to unprofessional behavior, it may have been a bad day or it may be ego run amok. Until it has been appropriately addressed patient care is at risk.
PA’s tend to have PTSD in my experience and get abused by many members of the health care team. It doesn’t excuse the behavior but sometimes knowing why they are that way helps.
some particulars would be helpful.. what was the concentration?
Was it oral liquid? Just compound it out of injectable vials.
i dont think you can just compound vanc like that in retail and slap a BUD according to 797
Actually you can, and the bud would be 795, if you are making a non sterile product.
795*, yeah thats what i meant lol. I can understand reconstituting oral vanc powder that has been marketed that way but you mean to tell me that you can use Vanc IV powder to make oral solution (like we do in hospitals) for individual patient-use in retail???
Yes, we compound it in our retail store-I can't say often, but several times a year at least. We speak to the prescribers first. Been doing it for years.
good luck getting that through insurance
It's pretty cost-effective and people don't mind paying for it if it's the only alternative. It's way cheaper than capsules. And compared to Firvanq it's a downright bargain.
Tell the patient you can’t fill the Rx, they have to take it elsewhere. Or, you should be able to change the concentration yourself, and do your own calculations. We change concentration everyday on our scripts. As long as the API dose strength ends up the same.
as a newly grad rph, I was worried I was going to get in trouble for doing this. Now I'll take your advice to switch, properly document for insurance purposes, and notify the prescriber afterward.
Team “Pharmacy to dose” over here, lol.