Cert Exam 5e Chapter 4 Presentation

[Audio] Welcome to the Certification Exam Review Fifth Edition presentation for chapter four..

[Audio] Chapter 4: Order Entry and Processing. Chapter 4.

[Audio] At the end of this chapter, you will be able to: Explain when generic drugs can be legally substituted for prescribed brand-name drugs. Interpret common pharmacy abbreviations and medical terminology. Describe the process of maintaining and updating patient profiles, including insurance information. Identify the components of prescriptions. Identify the components of medication orders and describe how they differ from prescriptions..

[Audio] Describe the process of online claims submission and troubleshooting rejected claims. Compare and contrast the processes for filling, labeling, and verifying prescriptions and medication orders. Identify the role of the pharmacist throughout the steps of the order entry and fill process. Identify the medical equipment, devices, and supplies used to administer drugs, and describe their uses..

[Audio] Section four point one: The Filling and Dispensing Roles of the Pharmacy Technician.

[Audio] In all settings, the goal of the profession of pharmacy is to provide the right patient with the right drug, at the right strength, with the right route of administration and in the right form, with the right documentation, and to deliver the right education material, all with 100% accuracy. Though the prescribing and filling processes differ between community and institutional pharmacy settings, both prescriptions and medication orders depend upon complete patient-medication and allergy profiles and the shared language of pharmacy abbreviations..

[Audio] Pharmacy technicians in all states are permitted (or in some cases required) to substitute the appropriate lower-cost generic drug in place of a prescribed brand-name drug without physician approval if the generic drug is considered bioequivalent. To be bioequivalent, the generic must be both pharmaceutically and therapeutically equivalent to the brand-name drug. To be pharmaceutically equivalent, the generic drug must contain the same amount of active ingredient in the same dosage form. Bioequivalent generic drug products may differ in certain characteristics, including shape, scoring configuration, packaging, inert ingredients, expiration date, and—within certain limits—labeling. Each generic drug also needs to be therapeutically equivalent, or provide the same medicinal benefit at the same dosage with the same degree of safety under the conditions specified in the labeling. This means that the bioequivalent generic drug enacts the same standards of safety and efficacy as the brand-name drug. However, since not all patients will respond similarly to a specific drug, the prescriber is permitted by law to write, "D-A-W" or dispense as written on the prescription. to indicate that the generic drug should not be substituted. The patient may also specifically request a brand-name drug, which would be written as "DAW2" on the prescription for insurance processing. This generally results in a higher copay, so the technician must make sure the patient is aware. Conversely, a patient may request a lower-cost generic, even if the physician wrote "brand necessary." In this case, a call to the physician's office is necessary to gain approval for the generic drug in place of the brand-name drug..

[Audio] Each step in the filling and dispensing processes for prescriptions and medication orders is an opportunity to do things correctly or to make an error. At each step, there is also chance to catch and correct any previous errors. The steps include: Receive and review prescription Enter prescription into the computer Perform Drug Utilization Review and resolve medication issues Generate a prescription label Retrieve the medication Compound or fill prescription Obtain pharmacist review and approval Store completed prescription Deliver medication to patient.

[Audio] Biological drugs come from a variety of live or once-live sources, including animals, humans, and microorganisms, such as yeast, bacteria, and fungi. These drugs include expensive injectable drugs used to treat genetic disorders, various blood disorders related to cancer or chemotherapy, and various inflammatory diseases, such as rheumatoid arthritis. Biological reference product refers to when a brand-name biological drug is patented and FDA approved and is used for all similar biological drug products to come. Because biological drugs come from live or once-live matter or organisms, they cannot be chemically reproduced with exactitude, so a generic version cannot be designated as pharmaceutically or therapeutically equivalent. Instead, the FDA has evaluated and approved biosimilar drugs, which are similar though not identical to the parent innovator drugs. They have been proven to address the same indications with the same pharmaceutical mechanisms, or precise ways that the active ingredients exert their influence on the body. Biosimilar drugs must also have the same administration routes, dosage forms, conditions of use, and levels of quality and strength as the original biological drugs. If a biosimilar drug is tested and found to be both similar and provide similar levels of therapeutic results, the FDA can designate it as an interchangeable biological drug, which is both biosimilar and therapeutically effective. Once a biosimilar drug is designated by the FDA as an interchangeable biological drug, it can legally be substituted for the prescribed brand-name biological drug without contacting the physician for approval, like a brand-name to generic drug substitution..

[Audio] Section four point two: Common Pharmacy Abbreviations.

[Audio] Pharmacy personnel must recognize all shorthand abbreviations used in prescriptions and medical orders. This table lists common prescription abbreviations for amount, dosage form, and time and site of administration. Focus and attention to detail are critical when reviewing a prescription or medication order. Note that when the units are abbreviated, there is minimal visual difference between gram (g) and grain (gr), but 1 gram is equal to 1000 milligrams and 1 grain is equal to 65 milligrams, so potential exists for a dosage error. That is why metric measurements are safest for prescribers to use..

[Audio] Abbreviations for dosage forms are usually straightforward. Many generic drugs are available in both capsule and tablet formulations and can be used interchangeably if they are in the same dosage strength. In some cases, the prescriber may write a prescription for tablets, but if the capsule is in stock, it can generally be substituted if approved by the prescriber. Prescriptions written for the eyes and ears may be solutions or suspensions; there is a subtle difference between these dosage forms, and they should not be interchanged without the approval of the prescriber..

[Audio] Section four point three: Patient Profile.

[Audio] Each time a patient presents a prescription or refill at the pharmacy or hospital, the technician or admitting nurse must create or update the patient profile. This profile includes: Identifying information, such as the patient's full name and address. Insurance information Medical and allergy history Medication and prescription history Patient requests And an indication that the patient has received Health Insurance Portability And Accountability Act confidentiality statements. The pharmacy software program uses the profile for processing the Drug Utilization Review to provide alerts about potential adverse reactions, medication conflicts, and allergies, and the pharmacist uses the information in the profile to help counsel the patient. The profile contains the patient's medication history, which tracks all the drugs the pharmacy has dispensed to the patient. When a patient requests a refill without the previous medication container or prescription number, the technician can retrieve the prescription information from the patient's medication history..

[Audio] Patient Privacy and Health Insurance Portability and Accountability Act Regulations In addition to providing personal and medication information, each new patient or their guardian must sign a Health Insurance Portability and Accountability Act or HIPAA form and designate those with whom their medication history information can be shared. A scanned version of this document must be added to the patient profile. Technicians must be on guard to keep prescriptions, medication history, profile, and other patient information confidential, or they are breaking the law..

[Audio] After reviewing a new prescription or refill order, the technician is responsible for updating any changes to the patient's demographic and insurance information. If a patient has more than one prescription insurance plan or any coupons/manufacturer discounts, the technician needs to enter all payment data before submitting the claim. A new patient to the pharmacy must be asked to provide all payment sources prior to filling the prescription. Verifying patient insurance information up front reduces unnecessary requests to insurers, which reduces the pharmacy's time and financial investment, and which decreases customer wait time. To begin the process, the technician asks for the customer's prescription insurance card to input the information into the computer, or to double-check it against the existing profile. Common components of an insurance identification card include: name of the insured person and the primary insurance carrier along with other family members covered (sometimes) The insurance carrier patient identification number (sometimes known as subscriber ID)— designating the insurance holder person code—indicating the relationship to insurance holder.

[Audio] 5. bank identification number or B-I-N—6 digits designating the pharmacy benefits manager 6. processor control number or PC-N-)—designating the kind of plan and processing flow 7. the date coverage became effective 8., the amount of the copay for generic and brand-name prescriptions (and other tier payments).

[Audio] Each patient will have a patient identification or I-D number and will have different person codes, even for shared family plans. The primary insurance holder's person code is 01 , and their spouse's code is 02. The person codes for dependent children would be 03, 04, 05 , and so on, generally in their birth order. Always double-check that the right person code was entered for the patient. Insurance card formats are not standardized, so getting all the necessary information may not be easy. For repeat or returning customers, you must ask if any information has changed, insurance if the card is still up to date, and consider asking if the patient's insurance has been updated since the last time they were seen at your pharmacy. f the cardholder's employment status has changed, the drug insurance on the profile will likely have changed. A patient may also be dual eligible, having more than one insurer. If so, the information on both cards must be entered into the patient profile, designating which insurer is the primary carrier and which is the secondary (and sometimes even tertiary) carrier. The B-I-N and P-C-N identify the correct pharmacy benefit manager or P-B-M and the internal processing code for the patient's plan. Some insurance cards do not list a P-C-N, making the technician's job a little more difficult. Insurance and Medicaid funded programs may switch P-B-Ms within the calendar year without notifying patients or issuing new insurance cards, so P-B-M information must be identified and updated with each patient visit..

[Audio] Section four point four: Components of a Prescription.

[Audio] A prescription may be submitted by computer as an electronic prescription (e-prescription), paper, phone, or fax. The components include: The prescriber's name, address, telephone number, and other identifying information, including state license number, D-E-A number, and National Provider Identifier The date on which the prescription was written, which may not be the same day the prescription was received Basic patient information like full name, address, telephone number, and date of birth The R-X symbol, which stands for the Latin word recipe, meaning take The inscription which is the medication prescribed, including generic or brand name, strength, and amount.

[Audio] The subscription, which is instructions to the pharmacist on dispensing the medication. The signa, which is directions for the patient. Any additional instructions that the prescriber deems necessary. And the signature of the prescriber. E-prescribing can minimize forgeries and the risk of potential medication errors resulting from failure to understand a prescriber's handwriting, misinterpretation of abbreviations, and illegible faxes. Prescriptions can be phoned in or faxed to the pharmacist and then transcribed into the patient profile. State laws also determine whether technicians can take refill prescriptions over the phone. With all refill prescriptions, technicians must check for accuracy and any changes or additions to the patient profile..

[Audio] Here is an example of what a written prescription might look like. Note how each component appears. Important components include the prescriber's DEA number, the NPI number, the signa, the inscription, and the subscription..

[Audio] In addition to checking for completeness, the technician must review prescriptions for accuracy. Often the prescriber's name is preprinted on the prescription at the top with address, phone number, and pertinent licensing numbers. If not legible or preprinted, the prescriber's name may be identified in the pharmacy's database by telephone number or by the National Provider Identifier or N-P-I. The prescriber's state license number is sometimes required by the state, and the NPI number is usually required by insurance for reimbursement. If the prescription is for a controlled substance, such as a narcotic pain medication, nerve medication, sleeping medication, or diet meditation the prescriber must have a federal D-E-A number on file in the pharmacy database and on the prescription. This number differs from a state license number and the N-P-I. If the D-E-A number is not listed or available, the technician may have to call the prescriber or their nurse and request it. Check the date the prescription was written. Do not assume that the prescription was written on the same day the pharmacy received it. If the date is missing, a follow-up call to the prescriber is necessary, or the patient may need to get a new prescription. The prescription can be filled up to one year from the date written, unless it is for a controlled substance (which is generally six months from date written)..

[Audio] The technician must also verify the patient's name. It is not uncommon for two patients to have the same first and last name. Some patients may prefer their middle names instead of their first names, making locating the patient record in the pharmacy database a challenge. Note, however, that third-party payers require claims to be submitted under the name listed with the insurer. Asking the patient's date of birth, even if already on the prescription, is an effective way to verify that the pharmacy records match the correct patient. Write the patient's date of birth on the prescription. It's also important to verify the patient's current address and phone number..

[Audio] Controlled substance prescriptions must follow all the federal requirements covered in Chapter 2. Check that the prescriptions follow these guidelines: Whenever state and federal regulations of controlled substances conflict, apply the more stringent regulation. Prescriptions for Schedule II (C-II) controlled substances require secure transmissions or a signed hard copy; the prescriber may not fax or phone in such prescriptions unless permitted by state law. Most—but not all—states allow the dispensing of certain Schedule V (C-V) controlled substances, such as cough syrups, without a prescription. The customer must be 18 years old or older, and they must present appropriate identification and sign a tracking log. Limited amounts are allowed for sale at one time..

[Audio] Section four point five: Components of a Medication Order.

[Audio] Medication orders are used by prescribers to request pharmaceuticals for patients in hospitals and other institutional settings. A medication order is typically delivered by a computerized prescriber order entry or C-P-O-E system. The prescriber transmits the order to the pharmacy or enters it into the patient's profile, and the pharmacist verifies the order for accuracy and patient safety before the technician begins the filling process. A medication order can also be conveyed via hard copy. The information on the medication order is then reviewed by the pharmacy technician and entered into the patient profile in the computer for pharmacist approval. At the time of administration, nurses reconcile the medication with the order and patient through an electronic medication administration record (eMAR) by scanning the bar code on the medication and the patient's wrist band before administering the first dose..

[Audio] There are several ways in which a medication order differs from a prescription, including: Instead of directly dispensed to the patient, medication orders are filled and delivered to the patient's unit to be administered by nursing personnel in a hospital, nursing home, or other medical facility. Types of Medication include admitting order , daily order, continuation order, standing order, stat order, and discharge order . Hospital medication orders must be renewed more frequently. Orders for antibiotics and narcotics often have an automatic stop order or A-S-O after a given period. Medication orders are dispensed until the order is changed or discontinued.

[Audio] Most dispensed medications from a medication order must be part of the hospital formulary, Hospital medication orders are often for medications administered intravenously (IV), such as parenteral and nutritional solutions, antibiotics, or other medications. Medication orders can also be prepared for investigational drugs through studies approved by the hospital's institutional review board (IRB)..

[Audio] Section four point six: Online Claims Submission.

[Audio] All medications have a National Drug Code to identify them, and this code is a key component in the online claims submission process. When entering and submitting prescriptions into the pharmacy software for the D-U-R, the software or technician transmits the prescription online to the pharmacy benefit manager to complete the crucial online insurance adjudication. Online adjudication electronically submits the prescription billing claims to the appropriate P-B-M to determine if reimbursement will be provided. The P-B-M's online response then states the proportion of the pharmacy reimbursement as compared to the average wholesale price or A-W-P and the patient's out-of-pocket costs. It usually takes less than 30 seconds to receive a reply from the P-B-M..

[Audio] The message from the PBM usually confirms payment of a claim, also known as claim capturing. The adjudication usually includes information on preferred formulary products that will lower the copay or adjusted copay for certain choices. Pharmacy technicians and pharmacists should look at the claim capture screen and make sure the pharmacy is not losing money on the transaction. If this is the case, alert the pharmacist so another product or generic can be suggested or substituted based on the patient's policy..

[Audio] While adjudication usually results in claim capturing, sometimes it results in a rejected claim, often accompanied by a reject code. Claims get rejected for many reasons, including problems with missing or mistyped information, wrong birth date, wrong name, wrong dosages, or special medications requiring prior authorization. Each rejection message requires its own response action to resolve the problem. If questions about coverage arise, the technician should use the appropriate toll-free insurance or P-B-M contact phone number..

[Audio] Section four point seven: Filling a Prescription or a Medication Order.

[Audio] For all prescriptions, medication orders, and for specialty compounding, D-U-Rs must be performed. The D-U-R will provide alerts for any problems from drug/drug, drug/allergy, drug/medical condition, or drug/supplement interactions. All issues must be resolved by the pharmacist (often with assistance from the technician by contacting the prescriber's office for more information). For many prescriptions, the technician will have to calculate dosage conversion and days supply. For both prescriptions and medication orders, a patient label or fill list is generated. The technician uses the drug name and strength to select the correct medication, scanning the NDC bar code to aid in identifying the exact drug, dose, and package size. The NDC number and bar code are on the stock drug label and unit dose packaging..

[Audio] The first number set, or labeler, designates the manufacturer; the second number set indicates the strength, dosage form, and formula; and the last number set, or product code, or package code, indicates the size and types. Each drug product is also assigned a lot number, or control number, by the manufacturer that identifies its manufacturing batch and date. The date of manufacturing determines the expiration date. This lot number allows the product to be traced if there needs to be a product recall because of some contamination to this specific batch..

[Audio] After confirming the N-D-C on the stock bottle, the technician may have to reconstitute a product according to manufacturer instructions and then make a notation of the expiration date on the label. (Flavorings may also need to be added.) The expiration dates are determined by the manufacturer's guidelines. Medications must be dispensed in the proper containers. Most pharmacy containers used for tablets, capsules, and liquids are amber-colored plastic or glass to prevent ultraviolet (UV) light exposure that can cause degradation of the medication. Any product packaging from the manufacturer ensures stability and potency until the listed expiration date. To comply with the Poison Prevention Packaging Act of 1970, all medications should be dispensed in child-resistant containers unless specifically requested by the patient. The caps on these containers are designed to be difficult for children to open. Certain drugs in original packaging are exempt from this requirement, for example, nitroglycerin sublingual tablets..

[Audio] Patient information about use, warnings, side effects, and storage are very important. There are five distinct ways of communicating necessary medication information to the patient: (1) medication container label, (2) auxiliary labels, (3) medication information sheet, (4) an F-D-A-mandated Medication Guide for select medications, and (5) counseling by the pharmacist..

[Audio] After medication review and verification by the pharmacist, the medication container label is affixed to the container of prescribed medication. It : the date dispensed; name, address, and phone number of the pharmacy; R-X number; patient name; number of refills; prescriber name; drug name; dose; directions; and manufacturer. The label's instructions must read as indicated in the signa on the original prescription. Some pharmacy labels also include a description of the medication. The storage information on the labels is significant to maintain medication stability and potency. For example, most reconstituted antibiotics require refrigeration and expire after 14 days. Vials of insulin at room temperature often have an expiration of 28 days before they lose some potency. Medication container labels for Schedule two through five drugs must contain a transfer warning that reads, "Caution: Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed.".

[Audio] Orders in the hospital are filled and delivered through daily unit dose carts, emergency carts, automated dispensing units on the nursing floor, or compounded parenteral medications that are delivered to the patients' rooms as needed. The steps to fill a medication order include: Physician writes the medication order on the patient chart or enters the order in the computerized prescriber order entry system . •• The order is transmitted via computer to the patient profile. The technician or pharmacist would transcribe it into the profile. •• The medication order is reviewed for accuracy and safety by the pharmacist. •• A cart unit fill list per nursing floor or station is generated from the medication orders for the new 24 to 72 hours for patients in that unit. The medication order list is checked by the pharmacist for accuracy. •• The technician fills each patient medication drawer in a unit dose cart by selecting the correct medications at a pick station. •• The pharmacist reviews the unit dose cart according to the generated list or patient profile..

[Audio] Pharmacy technicians are then responsible for delivering the medication cart to the nursing unit. This is usually done once a day in a large acute care hospital, though the cart may carry medications for more than one day in a smaller hospital or long-term care facility. •• Stat orders are processed separately from the unit dose carts. They are given top priority by technicians and delivered quickly for the nurse or doctor to administer immediately. •• Emergency crash carts are checked and refilled by technicians with all the most commonly used emergency medications, so they are always at hand..

[Audio] Section four point EIGHT: Final Check by the Pharmacist.

[Audio] It is extremely important—and required by law—that the pharmacist checks every prescription and medication order to verify its accuracy before it is dispensed to the patient or sent to the nursing unit. Typically, in a community pharmacy, the pharmacy technician will present the prescription printout or original hard-copy prescription, the medication information sheet, and the labeled container with the prescribed medication to the pharmacist for a final check. The pharmacist reviews the original prescription, compares it with the patient profile, confirms that the medication information sheet has been printed, verifies that the drug selected by the technician (from the stock bottle) is correct, and checks the accuracy of the medication container label..

[Audio] It is extremely important—and required by law—that the pharmacist checks every prescription and medication order to verify its accuracy before it is dispensed to the patient or sent to the nursing unit. Typically, in a community pharmacy, the pharmacy technician will present the prescription printout or original hard-copy prescription, the medication information sheet, and the labeled container with the prescribed medication to the pharmacist for a final check. The pharmacist reviews the original prescription, compares it with the patient profile, confirms that the medication information sheet has been printed, verifies that the drug selected by the technician (from the stock bottle) is correct, and checks the accuracy of the medication container label. In the hospital, the medication order, label, compounding procedure, preparation records, and all materials used to prepare or make a C-S-P must be inspected by the pharmacist before the medication is sent to the nursing unit. The inspection should include verification of the identity and amount of ingredients, technique for aseptic mixing and sterilization, packaging, labeling, and physical appearance. A pharmacist will also perform a physical check to look for incompatibilities between the additives and an IV solution..

[Audio] Section four point nine: Equipment and Supplies Required for Drug Administration.

[Audio] When dispensing medications, it is important to provide the proper dosage delivery devices for use by the patient, parent, or caregiver. These devices are calibrated and marked to proper measurement of the intended dose. This section will discuss various dosage delivery devices. Devices for oral administration include cups, droppers, calibrated spoons, and oral syringes. They are typically marked to measure in teaspoons, tablespoons, or milliliters. Medication is poured into the cup and measured at the bottom of the meniscus for accuracy. Droppers are usually used to measure small amounts of liquid to the eyes, ears, or mouth. Droppers are calibrated by the manufacturer for use with a specific product and should not be interchanged. Calibrated spoons are used for volumes up to 5 mL. The medication is poured into the hollowed portion of the spoon using the proper measurement and then administered to the patient orally. Oral syringes are the most used oral administration device. They typically come in 1, 3, 5, and 10 milliliter sizes and are chosen based on the intended volume of the dose. Sometimes an oral syringe is used with a bottle adapter, which is a small insert that fits into the top of a bottle and allows the user to draw out liquid from the inverted bottle..

[Audio] Syringes for injection should not be confused with oral syringes. Injectable syringes allow administration of a medication by IV, IM, or another injected route using a needle. Syringes and needles come in various sizes. Both are disposable and should not be reused. Always dispose of used needles in a sharps container. Many patients with diabetes administer their insulin using syringes and needles, but others use pen systems to deliver precise doses of insulin. When using insulin pens, patients with diabetes will need pen needles, which are thin, short needles for subcutaneous injection. The higher the number, or gauge, of the needle, the smaller the size of the needle. Other supplies for patients with diabetes include blood glucose test strips, lancets (for pricking the finger to obtain a blood sample), and quick-acting sources of glucose (typically tablets or gel) to treat low blood sugar..

[Audio] Unit-use items are usually dispensed in their original packaging and can include items like medicated shampoos, creams, or lotions. These may be difficult to label due to the size and configuration of their packaging, so consult with your pharmacist if you have doubts about label placement. Unit-dose items are most often used in the hospital where medications are prepackaged for single administration. Patients with respiratory conditions who receive medications via inhalers often receive spacers with their devices. Spacers attached to certain inhalers hold the medication in a chamber until it is breathed in by the patient..

[Audio] This concludes the Certification Exam Review Fifth Edition presentation for chapter four..