RE: calling a doctors office

[Guest guest]

Dear ALL, especially Jule,

I waited to respond because I wanted to get permission from a memmber

who had written an email privately to me one day before Jule posted

last on this topic. I felt it may shed some light. I got the okay this

morning and a reply to my instruction. I will post the original email

and my first reply here and follow up with the second email and my reply:

The following was sent to me during the heated discussion between Joe

Medina, Jule Barta, myself and others regarding if a tech can take a

verbal order over the phone and offering alternative suggestions:

" I've been following the dialog on the site about techs contacting the

doctor and suggesting alternatives. My company uses PDX and when we

get a reject for a particular drug it also gives acceptable

alternatives. I don't know if this is a function of all PDX programs

or just ours. I print out the reject page with the alternatives

listed and pass that and the script down to the RPh. We are a clinic

pharmacy, and I don't know if that makes any actual difference, but

I'm the one that usually call the doctor's office and speaks with the

nurse, or leaves a message, telling her of the rejection and informing

her of the alternatives. Although I usually know which drugs are

preferred on our formulary I never make these calls without the RPh

seeing the reject first. It's pretty rare that the doctor will call

back with a change, it's almost always the nurse calling us back; I

think I'd be mighty suspicious if any nurse made a drug change on the

spot without consulting the doctor first. At one point my RPh, who I

absolutely love, would get annoyed with me for not taking down the

drug change when the nurse called back but he is completely broken of

this habit now - I absolutely refused to do it. I've taken on alot of

work for him, ordering, billing, inventory, etc, the list goes on, but

when it comes to areas like this I will not do it. I'm still refusing

to do the CII book and he's stopped expecting me to. Yeah! "

" Another twist at our pharmacy is the collaborative agreements, CA's,

that my RPh has with several doctors within our system. These

agreements allow him to switch from one drug to another, within preset

parameters, at his discretion and without first contacting the doctor.

After he has made any type of switch he goes into our company's

patient database( that only authorized and trained people can access)

and leaves a note in that patients profile and in the RPh notes

indicating what switch was made and when. These CA's only cover

certain types of meds within the doctor's scope of practice, the

OB-GYN's don't do BP meds, etc., and the only involvement I have is

that I need to know which doctors have CA's with us so I can tell the

RPh when I get a drug rejection; we switch it right away and clear out

the rejection. In our area (location) my RPh is the only one who has

set up these agreements, although the company would like other RPh's

to do it. My RPh is the only PharmD in our area who is in his age

bracket, 30+ years old, so that might have something to do with it.

Some doctors don't want to participate. I have on occasion written

out the script for the change, but my RPh always signs it. I don't

feel real comfortable doing this yet but my RPh assures me it's all

legal and legit. "

Name Withheld

For obvious reasons the above person cannot give his/her name. But

this person is in the state of Wisconsin which is relevant to the topic.

On July 22, 08 via email I asked this person IF I could post this. I

also responded to the above email and questions posed to me privately

in the following manner:

" Dear Naem Withheld,

Always a pleasure to hear from you. I would like to thank you for your

well written description of what happens at your pharmacy. Glad to see

you putting your boss in the 'pharmacists' place! I do not know

how legal or illegal writing down a script is in your state. To my

knowledge this is not legal. It is legal for a tech to write a script

from a recording, fill it and have a pharmacist check it. But what I

do not know is this: does the pharmacist sign it or must he/she

rewrite it in his/her writing?. So if your state does allow techs to

write a script from a recorded message then I would not write out that

script that you spoke of.

However it is legal for a nurse or other physician's assistant to

write a script and then have the doctor sign and date it. A physician

MUST sign and date all scripts including CS scripts EXCEPT in states

that do not allow this. (Recent law change, however a pharmacist is

not a doctor or physician, but the law may read prescriber, in that

case one who writes the prescription is the prescriber). I hope this

makes sense to you. Just DON'T under any circumstances DATE the

script! (of course do not sign it). CHECK your state laws yourself

meaning do not allow the pharmacist to TELL you that it is legal. This

is NOT a defense in a court of law. He has wanted you to do other

things that are not legal (CS CII stuff). Do not fall for this. Be

responsible and check out the law yourself to feel more comfortable or

to put the written law under his nose if he is wrong!

May I please post this real live scenario as I believe it will help

others who just do not understand the law or are being told by their

pharmacists what is law and what is not but are wrong.

Hope this helps you. Let me know.

Love ya

Jeanetta Mastron CPhT BS "

Okay all I will follow up with this person's reply that I got back

JUST this am!

Respectfully,

Jeanetta Mastron CPhT BS

Founder/Owner of this site

> From: Jule Barta <julebarta@...>

> Subject: Re: calling a doctors office

>

> Date: Tuesday, July 22, 2008, 6:33 PM

>

> Joe I am so sorry that I did not respond to you about your books. I

have had

> several students use them and think they are great. I have asked the

> students themselves to email and thank you. I am very disappointed

to hear

> that none of them did so. So far my students have had a 100% pass

rate this

> year and I owe part of that to you Joe, Jeanetta and several others

on this

> list. Again thank you for your generous gifts! I make the students

return

> the books after the test so others may continue to learn.

>

> Why I teach my students to research alternatives in my class.

> Most often it is the tech calling the doctor's office and relaying a

message

> to a nurse of medical assistant. Very rarely in a retail setting have I

> talked directly to a Doctor. Several of the pharmacists I had would

tell me

> to make the call give the information and then get them when the

doctor was

> ready to talk to them.

> Remember my students are taught to look up alternatives and inform the

> pharmacist " these are what are covered what do you suggest the

doctor change

> it to " I also spend a lot of time going over what questions my

students can

> and cannot answer. If a doctor gets on the phone the students are

taught to

> immediately transfer it to the pharmacist as they can only relay the

> information that was confirmed by the pharmacist. They can not offer any

> advice or opinion.

> My experience is in retail, and remember the majority of the time we are

> just leaving messages. If the technician can look up the information and

> have alternatives ready for the pharmacist he/she can then make the

> therapeutic decision.

>

> In a hospital setting it is much different and there pharmacists usually

> talk directly to the doctors.

>

> I will disagree on techs being able to take new prescription orders.

I think

> they should be allowed to do this. I do believe they should receive

higher

> training and pay for this. What is the difference a medical assistant

> repeating an order to the pharmacist (which is legal) who may have

received

> little to no training, a nurse leaving a message on an answering

machine and

> not talking directly to a pharmacist, a 1st year intern taking a new

> prescription, or a tech taking the information? All are perfectly legal

> except for the technician who in my experience often has more

training than

> the pharmacist intern or medical assistant.

> Yes if questions arise the pharmacist should be brought in. Yes all the

> prescriptions should be reviewed and verified by the pharmacist.

There are

> my 2 cents.

>

> Julette Barta CPhT, BSIT, MA Ed.

> Pharmacy Instructor

> CRY-ROP

> PO Box 8640

> 1214 Indiana Ct.

> Redlands, CA 92374

> Cell 951-741-4011 Fax 909-793-6901

>

>

>

> Internal Virus Database is out-of-date.

> Checked by AVG Free Edition.

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11/14/2007

> 9:27 AM

>

>

>

>

[Guest guest]

Dear All,

This was the reply that I got back today July 28, 08 about a week

after the original was sent and my reply on July 22,08:

Dear J.,

Sorry I didn't get back to you before now. Had some personal business

to take care of.

The site is such a valuable learning tool. (I really wish I was more

comfortable posting directly onto the site but I'm not - someday I

will be for now I'm not.) After I got your reply I questioned my RPh

about my writing out scripts of any kind. He does not remember if

I've written out any for his CA's, he now says I am not allowed to do

this and he does them all - kind of a flop from what he said

previously, but perhaps he's had some time to mull it over, but he

recalls I do write out the ones for patients that are discharged from

the hospital, he says those scripts are just a transfer.

When a patient is out of refills I can generate a call doctor slip

that PDX faxes automatically and then prints out - I have taken an

authorization over the phone and written the number of refills

authorized on that printed out fax form. When asked if he knows for

absolute sure that my doing these things is 100% legal he had to admit

that he was only pretty sure. I said I was going to do some checking

on the state (Wisconsin) site and would present him with that

information so we would both know what is and isn't allowable. I will

also be searching through all scripts for the last 7 months to be sure

anything I may have done falls within those allowable limits and

whatever isn't he will be writing over. He is very agreeable to all

of this.

Here is what I've found from my state site - I can take the oral

authorization 'providing there are no changes to the original

prescription order' - this would cover the oral authorizations I get

from the call doctor fax PDX generates. I can also 'accept written

and electronic prescription orders of the prescribing practitioner or

his/her agent' - this one is kind of snaky. This should cover the

hospital discharge orders with continuing and new drug orders included

but it's not very specific is it? NO WHERE did I find that I can

write the scripts for the CA's. I can NOT 'make independent

theraputic drug selections' and ' may not participate in final drug

regimin screening, including screening for thearputic duplication,

drug to drug interactions, incorrect dosage, incorrect duration of

treatment, drug allergy reactions and clinical abuse or misuse'. I

think " final " is the operative word here, if I provide the RPh with

copies of the PDX DUR and rejects I'm not actually doing the " final "

anything but if I override those things, as we are all trained and

given the override codes to do, then I am deciding the " final "

outcome, aren't I? I'll need to be more careful in what I do -

override only the insufficient quantity, generic available rejects.

My regular RPh is on vacation until August 3rd so I can't discuss any

of this with him until then. I was off on Wednesday and he left on

Thursday so I haven't seen him since last Tuesday. When I came in

Thursday, I worked with a RPh I had only met once and had never worked

with, and my RPh had left me a pile of notes with lists of things for

me to do that he didn't get done before he left. One of the things

was 'check in the CII delivery'. I immediately gave that to the sub

RPh and said I'm not doing this. That poor RPh!! He spent ALL day

reconciling the CII book. Nice that he did that BTW. First off he

couldn't find all the 222 copies to write in what my RPh hadn't done

yet, one of those that my RPh had sent off to our supplier without

keeping a copy; that came later that day. He also found 4 different

drugs that were off, one as much as 300+ tablets. I'm so glad I

decided to not have anything to do with that book! Friday we got

another drug order in and more CII's, which I gave to a different sub

RPh, a pharmacist I know and have worked with before, again saying at

this store it's the RPh's responsibility. He said he wasn't going to

do it because he's just a float and I'm the regular employee. I was

firm in my refusal. He set it aside and it has yet to be done. His

attitude about this ticks me off as he has told me for the last 4

weeks that I have to have ALL our bubble packing done before it was

his turn to fill in as he wasn't going to do any bubble packing - we

inherited this packaging from his store when it was closed and he did

it all the time then, alone too as he had no tech ever. I told him he

didn't have to do the packing as I did that, all he had to do was

check it but he was adamant that he wasn't going to do any of that

either. I saw or talked to him almost every day in July and every

time he said 'get that packing done because I'm not doing it'. I

busted my hump to get it done - I didn't manage to get it all done but

I did get all the really big ones done so all he has to check are the

1 to 3 pill ones but he's not happy about having to do even that. Now

he can insist that he's not doing something, and he's a regular float,

our store does bubble packing and he knew we do it at the end of the

month when he would be filling in, but I can't be equally insistent

that I'm not doing the CII book? That just doesn't sit so well with

me. I work with him today and tomorrow yet and I'm sure those CII's

will still be sitting there Wednesday morning.

I have decided that I've discovered there are 3 types of male RPh's -

I haven't worked with a female RPh yet within this medical group –

1. The ones who view techs as just a step up from a clerk, with no

applicable knowledge whatsoever, forcing them, mighty pharmacist, to

do everything, except run the cash register of course.

2. The ones who view themselves as above all " menial " tasks - they're

the PHARMACIST, they don't answer phones, run the register, enter

scripts, count, label, anything except counsel the patient - it's the

techs job to do all those things. The RPh I work with today and

tomorrow is of that type, he counsels only and the rest of the time

he's surfing the net.

3. The third type is the one who views the tech as an almost equal

partner and is willing to train and teach, allowing the tech to grow -

this would be Sam.

What I have now discovered from your site, techs helping and teaching

techs, is that if you have the great fortune to be aligned with a RPh

of the 3rd kind to count yourself lucky but also to look out for

yourself too. That 3rd type may ask you to do something that isn't

within the parameters of what a tech can do, not done maliciously, but

likely for the sake of learning and simply because he's not aware of

what a tech can and can't do.

As you said it's the tech's responsibility to know what is and isn't

allowed and ignorance is not a defensible position. (This situation is

an excellent example of why all techs should belong to at least one

state and/or national pharm tech group.) I had formal schooling, with

law classes, and I still had to look at the statutes (recently) to

answer these questions that come up, how does someone who just

self-studies for the PTCB or ExCPT exam work on a day to day basis

with confidence he or she are not breaking a law ? That'd be a whole

other discussion;-)

I have included this link to my state's pharm tech laws.

http://nxt.legis.state.wi.us/nxt/gateway.dll?f=templates & fn=default.htm & d=stats & \

q=pharmacy%20technicians

Sorry this is so long again. Do what you will with whatever I've

written - as long as identifiable references are removed. (I don't

want my RPh to get in hot water and I plan to fix whatever may be

outside my legal parameters.) As a somewhat new tech I'm happy to

serve as either a good example or horrible warning to other newer

techs. Thanks for all your help......again!!

Take care of you. Chat with you soon.

Name Withheld "

Hree is my reply today this am:

" Dear Name Withheld,

I am so very proud of you for taking and following my advice and

standing up to this pharmacist as I instructed you regarding the CII's

(form previous emails). Likewise for standing up to him and the

others regarding what you will and will not do due to your scope of

practice and the law.

Kudos for taking my advice and looking up your state law.

You are right:

1. You can take an authorization for are fill as long as there are NO

CHANGES to that order, including the quantity!!!!!

2. You are correct you can NOT make independent therapeutic drug

selections' and ' may not participate in final drug regimen screening,

including screening for therapeutic duplication, drug to drug

interactions, incorrect dosage, incorrect duration of treatment, drug

allergy reactions and clinical abuse or misuse'. But you CAN show or

suggest to your pharmacist any potential errors in the above so that

he or she can make the final changes and check.

3. The reason that you did NOT find that you can write the scripts for

the CA's is that you can not write a prescription even if your

pharmacist dates and signs it, from the law that you have quoted.

Recall " NO WHERE did I find that I can write the scripts for the

CA's. " Wisconsin is not one of the laws that allows a tech to take a

new verbal order over the phone or otherwise. Only written or faxed

scripts may be taken by a tech in your state as well as all but 41

other states. (see my previous postings on this). See point #4 for a

continuation of this topic.

4. So to answer specifically your question you may accept WRITTEN

hospital discharge orders with continuing and new drug orders, but you

may NOT accept oral or verbal live new orders. It is not clear to me

whether or not you are allowed to accept a recorded verbal order

because you have not indicated that Wisconsin state law says so. But

if you do I would suggest that your RPh re-write it on a Rx pad in

total with his/her handwriting (not just all except the date and

signature). This would show that he or she definitely listened to it

before it was dispensed with a final check, removing you from the

equation.

5. You are correct that if you provide the RPh with copies of the PDX

DUR and rejects that you are not actually making any suggestions for

therapy and you are not doing the " final " anything. You are also

correct that if you override those things, even if given the override

codes by the pharmacist, as many techs are trained to do and believe

it is okay to do because a pharmacist said so; IS a final decision and

a judgment call and NOT acceptable within the scope of practice for

any pharm tech!!! You are correct YOU as a technician can not override

these things listed above as it is a " final " outcome. You are correct

that you will need to be more careful in what you do. As far as over

riding only the insufficient quantity you are correct and placing the

specific generic substitute for th4e specific trade ordered by the

doctor. Any other substitution must be entered and documented by a

pharmacist.

6. I agree with you about the three different pharmacists! And then

some I have my own theory on the Newbies.

7. I also agree with you on your comment: " I had formal schooling,

with law classes, and I still had to look at the statutes (recently-

thank you for the advisement) to answer these questions that come up,

how does someone who just self-studies for the PTCB or ExCPT exam work

on a day to day basis with confidence he or she are not breaking a

law? That'd be a whole other discussion;-) " and my comment back is

the tech must check out the state and fed law quarterly! Take CE's on

law as often as possible, check out news on the state board site and

as you also stated belong to a tech organization, preferably one with

a state or local chapter.

Take care and thanks for allowing me to post this on the site. I think

we can all learn from it.

Love ya

Jeanetta "

Respectfully,

Jeanetta Mastron CPhT BS

Pharm Tech Educator

Founder/Owner of this site

[Guest guest]

Hello Everyone,

Just so everyone knows I NEVER give information to a doctors office. The

pharmacist did not reccommend anything. It was just a case where the customer

didn't want to pay $44 for something. So the doctor was called to see if the

patient could get something else.

 

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