Getting Started with Clinical Indications

How long does it take?

Longer than a few weeks, so start small. At Highfield Surgery, the pilot practice (5,800 patients at the time), indications were added as each repeat request came in, and it took one and a half years to reach 85% coverage of repeat prescriptions. In one week of observation, the practice produced 1,200 repeat items with indications attached (FAQ 3).

Who does what?

• The lead clinician, usually a GP, sets simple targets (FAQ 9).
• Prescribers add the indication and should remain medicolegally responsible for the wording (FAQ 7). FAQ 11 says all prescribers will need training.
• The prescription clerk runs the departure audit in the site’s example (see below).

Which phrases will you use?

Agree a list before you start. FAQ 7 asks for indications to be “standardised as much as possible” and recommends that prescribers pick phrases from lists rather than add them automatically. Keep each one short: ideally three or four words, such as “to lower blood pressure”. The Sample Directory is a starting point. It was compiled at Highfield Surgery from its repeat prescriptions and is an example, not a working directory, so check each phrase before you use it. See how to write a good indication.

At present, clinicians add the indication as free text to the directions on the electronic prescription. In EMIS, the free text is stored and offered from a pick list on future issues of prescriptions, for all patients. There is no separate indication field.

Which patients first?

FAQ 9 suggests working through patient groups:

1. patients over 75, then over 65: time-consuming, as many are on a large number of repeat prescriptions, but the most useful in the long term;
2. then groups such as patients with diabetes or heart disease;
3. or, as some practices have done, anyone on more than four medication items.

How do you tell patients?

• Mention clinical indications in the practice leaflet, in the repeat prescribing section, stressing the safety benefits (FAQ 4).
• Ask patients before adding an indication that may be sensitive; FAQ 4 gives epilepsy and cancer as examples. Patients who decline can have “patient preference no indication” on the prescription instead (see sensitive conditions).
• Patients in shared accommodation can be advised to be discreet with their medicines, as the indication may be on the label (FAQ 4).

How do you add them?

As each repeat request comes in: that is how Highfield Surgery did it. Write the indication as free text in the directions (FAQ 3). Dr Masters’ 2015 BJGP letter gives the example allopurinol “Take one daily to prevent gout”.

Who else should know?

Your local pharmacies and care homes. It is courteous to tell them that you plan to add clinical indications to your prescriptions. FAQ 15 traces the indication from the practice computer to the local pharmacy computer, and on to the medicine label at home or the medicine administration record in a care home. See pharmacies and care homes.

How do you check it is working?

With the site’s two audits (departure and destination audits), both carried out at Highfield Surgery:

The site’s method repeats the departure audit every six months.

How did patients respond at Highfield Surgery?

Feedback was “very positive”, and few patients asked for changes: in three years, two asked to change their wording and two others asked for no indication (FAQ 14). FAQ 9 hopes that, encouraged by feedback from staff and patients, adding indications “will soon start to become an everyday routine”.

See also clinical indications in GP practices and for prescribers.