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MODUL BCS
SEMESTER IV
ALIMENTARY & HEPATOBILIARY SYSTEMS and
PRESCRIBING SKILLS PHASE II
DISORDERS

Dr Ida Ayu Alit WIdhiartini, dra., Apt., M.SI

Desak Ketut Ernawati, SSi., Apt.MPharm., PhD

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 Time Schedule

Day?Time Activity PIC

9 Overview and Training Dr I A Alit Widhiartini, Apt.,

March 20, 2019 RATIONAL PRESCRIBING M.Si
Wednesday
15.00-15.50
10 Training Instructor BCS
March 21, 2019
Thursday
13.00-13.50
14.00-14.50
15.00-15.50
11 Overiew and Training dr Ni Wayan Sucindra Dewi,
March 22, 2019 P DRUG’s MBiomed
Friday
15.00-15.50
13 Training Instructor BCS
March 26, 2019
13.00-13.50
14.00-14.50
15.00-15.50

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PRESCRIBING in ALIMENTARY DISORDERSPPrescribing In Alimentary and

Hepatobiliary Disorders

Dra Ida Ayu Alit Widhiartini, Apt; M.Si.

ABSTRACT

Description

Prescribing In Alimentary and Hepatobiliary Disorders

Dra Ida Ayu Alit Widhiartini, Apt; M.Si.

ABSTRACT

Alimentary and hepatobiliary medications have been studied extensively. Some of the
medications are obtained easily from the pharmacies as over the counter medications e.g. antacid
for gastrointestinal acid suppressants in dyspepsia and peptic ulceration. Later, they went to the
doctorphysician too and may be prescribedcontained more than three too much drug
medicationand unefficients from prescriptions. They may take the medications simultaneously
without sufficient counseling about the therapy thatIrrational prescribing may lead to morbidity
and mortality. Furthermore, studies are raised and said that many p they may not need or they
may have longterm therapy whichthat is may not well informed on the prescription or or on
medication orderrecord. . This may lead to irrational drug use which may cause increase of
morbidity and mortality. Most alimentary and hepatobiliary medications have been studied
extensively as while partially dosage forms have been used daily as over the counter medicines
which easily get from small pharmacy counter and unrestricted use in the community.Further,
Llong term used of medications (i.e. ethical and drug (otcover the counter medications) without
supervision, consumption in other way may cause potentially dangerous for alimentary and
hepatobiliary system until problems to the alimentary and hepatobiliary system and others that
sometimes ignored by the patients..

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However, the alimentary and hepatobiliary disorders may influence the pharmacokinetic
properties such as absorption and metabolism process. Pharmacokinetic related to drug delivery,
hepatic pass effect, augmenting or inhibiting intestinal function, and food influence.
Pharmacodynamic changes of the medication also determine the drug of choice because the drug
efficacy related to the target specificity would be special consideration. Then, choosing the right
drug after establishing the diagnose is named “P” drug. This has been recommended by standard
book or formulary manual. The “P” drugs may be the first or the second drug choices which in
accordance to indication, dosage form and doses also frequency or interval drug administration,
and duration of therapy. Prescribing in alimentary and hepatobiliary disorders need to consider
the drug efficacy, safety, suitability and also the cost for the sake of t

herapeutic efficiency.

Objective: to provide an overview of rational prescribing in alimentary and hepatobiliary and to

encourage medical student to evaluate, learn and practice in aiming for improving the safety of
medication use. This would be achieved by customizing the patients needs on medication based
on indication, dose, dosage form, and awareness to the drug toxicity.
Outcomes :

At the end of training, the student must be able to prescribe medications safely, appropriately,
effectively and economically and be aware of the common causes and consequences of
prescribing errors.

Learning Objectives:
a. Establish an accurate medication history, covering both prescribed medication and other drugs
or supplements, and establish medication allergies and the types of medication interactions
that patients experience
b. Carry out an assessment of beneft and risk for the patient of starting a new medication taking
into account the medication history and potential medication interactions in collaboration
with the patient and, if appropriate, their relatives, carers or other advocates

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c. Provide patients, their relatives, carers or other advocates, with appropriate information about
their medications in a way that enables patients to make decisions about the medications they
take

d. Agree a medication plan with the patient that they are willing and able to follow

e. Access reliable information about medications and be able to use the different technologies
used to support prescribing

f. Calculate safe and appropriate medication doses and record the outcome accurately

g. Write a safe and legal prescription, tailored to the specific needs of individual patients, using
either paper or electronic systems and using decision support tools where necessary

h. Communicate appropriate information to patients about what their medication is for, when
and for how long to take it, what benefts to expect, any important adverse effects that may
occur and what follow-up will be required

i. detect and report adverse medication reactions and therapeutic interactions and react
ppropriately by stopping or changing medication

j. monitor the effcacy and effects of medication and with appropriate advice from colleagues,
reacting appropriately by adjusting medication, including stopping medication with due
support, care and attention if it proves ineffective, is no longer needed or the patient wishes
to stop taking it

k. recognise the challenges of safe prescribing for patients with long term physical and mental
conditions or multiple morbidities and medications, in pregnancy, at extremes of age and at
the end of life

l. respect patient choices about the use of complementary therapies, and have a working
knowledge
of the existence and range of these therapies, why patients use them, and how this might
affect the safety of other types of treatment that patients receive

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m. recognise the challenges of delivering these standards of care when prescribing and providing
treatment and advice remotely, for example via online services

n. recognise the risks of over-prescribing and excessive use of medications and apply these
principles to prescribing practice

DAY 1

Rational Prescribing

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Rational prescribing should be based on a series of a rational step that clarifying each of the
critical thinking of drug choice related to patient’s condition as present on figure 1.(Scordo,
2014; Loftholm, 2012).
1) Make a specific diagnosis
Prescription based on the patient’s condition and medication history related to the diagnosis
to fulfill the psychological need which are satisfied as an improvement or unsatisfied due to
adverse effect. The diagnosis and the reasoning underlying the diagnoses should be
communicate to the patient, some times patient’s family or patient’s care giver.
2) Consider the pathophysiologic implications of the diagnosis
The effective therapy must be offer based on patient’s pathophysiologic information which is
provided appropriately depend on the patient’s status. Sometimes the patient’s do not
understand how was their condition and for this the information should be delivered with
simple communication.
3) Select a specific therapeutic objective
Therapeutic objective derived from the pathophysiologic process information which is stated
as a main therapeutic goal which identifies the drug group of choice in prescription.
4) Select a drug of choice
The drug of choice could be single drug or multiple drugs based on the therapeutic goals. The
drug of choice (would the the P drug’s) among this group will be determined from patient’s
characteristics and the patient’s clinical presentation. The age, comorbidity, information of
drug allergy, experience in adverse effect or drug intolerance and also the cost of medication
determine the drug of choice. The saver, the more effective, the more suitable, and the lower
cost treatment would be rational choice.
5) Determine the appropriate dosing regimen
Dosing regimen is determined based on pharmacokinetic of the drug in that patient. The
clinical condition of the metabolic organ and the excretion organ such as liver and renal
should be considered to dosing safely. The dose regimen refer to the dose regimen from the
drug handbooks, manufacturer information, formularium implemented locally.
6) Devise a plan for monitoring the drug’s action and determine an end point of therapy
The prescriber should know the drug’s action such as the desired action which has the
positive effect to relieve the complaints and improve the patients condition even the negative
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effect such as the side effect or adverse effect which may happened. The prescriber should
explained the patient’s clinical changes related the drug effects so the prescriber may
stop/alter/modify the therapy and ask the patient to stop/continue with new regimen or
therapy.
7) Plan a program of patient’s education
Patient’s education would be an important thing in this decade. The drug information should
inform appropriately to motivate the patients to their therapy since they can access
information easily but sometimes misperception about the side effect and contraindication.

When Starting a drug treatment, physicians do communication with colleagues, pharmacist, and
also nurse by writing or typing the drug and the drug regimen comprehensively, continued by
monitoring also evaluating the therapeutic outcomes as summarized in Figure 2.

Patient’s problem

Make spesific
Diagnosis
1. Determine the goal of treatment
1.1 Consider pathophysiologic implication of
the diagnosis
1.2 Select a specific therapeutic objective: Relief
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symptoms/ cure/promote/rehabilitation/
preventation
2. Choose a P drug’s
2.1 Take/choose a first choice drug treatment
2.2 Verify appropriateness for the patient
Treatment
3. Start drug treatment
3.1. Write prescription/administer the drug
3.2. Inform, instruct, and warn the patient
3.3. Make next appointment
Result
4. Monitor the result
5. Draw conclusions
Conclusions
6. Determine further action

Further action 7. Stop/alter/continue therapy

Figure 1. Rational Steps when prescribing (Modification from: Loftholm and Katzung,2012)

The Prescription

Prescribing safely preceded by writing the legible prescription or medication order by

the registered prescriber with patient’s full name, specify the body weight in case of children,
age, and full address in good own handwriting, clear verbal or electronic prescription
/medication order. The medication will be written electronically or manually on a prescription
form for outpatients or ambulatory care patients (Figure 3) and on the medication order form or
on a part of patient’s medication record for inpatients in institutional health system such as
hospital, or institutional clinics (Figure 4). Prescription or medication order can be handwritten
or applied by electronic prescribing program which are typed, preprinted, verbal even
documented by computer program that is submitted to the pharmacist by the clinician, patients,
or patient’s care giver.
Prescriber’s full address state the accessible prescriber’s address or home base department
completely with active contact number. This information is very important when something
unclear and need any confirmation. Patient’s full name state the patient’s identity with his recent
anthopometric characteristics, such as body weight (kg/lbs), height (m), even body surface area
(m2) for infant and children and also the age. These characteristics determine the specific
quantity or dose of the medicine which is appropriate to patient’s need.

Prescriber must state the drug name using the generic name, the copies of brand-name
drugs which have the same in dosage form, safety, strength, route of administration, quality,
performance characteristics and intended use (from: www.FDA.gov). The drug name were
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printed on packaging. Some drugs only available in brand name with patent which protect the
production by the only original manufacture. (Cited from: WHO, 1996; WHO, 2001; Brook, N.
Harris, et al., 2013).

dr Nyoman Cermat
SIP:......
Praktek Jl….
No Telp. HP….
City, Date
R/ Drug name, Potency, Unit, Dosage form, packaging,
Amount , No…
Signa (direction to patient in how to take the medication
effectively)

Sign

Pro: Patient identity

Age: in years old BW: body weight in kg
Address: patient’s address

Figure 3. Prescription Form

RM.11.2/OBAT/2015

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Nama :
L/P :
CATATAN PENGOBATAN Umur :
Berat Badan :
OBAT No RM :
Alergi :

Tgl. Nama Rute Aturan

Mulai Obat & Pakai
Dosis
Indikasi ROTD
Tgl.
Stop Paraf (nama
Catatan dokter )

Figure 4 Medication Record Form

Medical Abbreviation Used in Prescription

The several direction for medication use are still written in Latin for several reasons such as
Latin, the universal language had been used in medical for years and lead to prescribe a clear,
concise term which is avoid misperception. Several Latin apothecary abbreviations are listed in
Table 1.

Table 1 Common Apothecary Abbreviation

Abbreviation Description
Aa ana sama banyak
a.c ante coenam sebelum makan
a.n ante noctem malam sebelum tidur
ad lib ad libitum secukupnya (yang diinginkan)
a.u.e = ad us.ext ad usum externum untuk obat luar
a.u.p= ad us.prop. ad usum proprium untuk dipakai sendiri
u.p= us.prop usus propius dipakai sendiri
m.i mihi ipsi dipakai sendiri
aq.bisdest aqua bisdestillata air yang 2x disuling
aq.dest aqua destillata air suling

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aq.steril aqua sterilisata air steril

c. cochlear (cibarium) sendok (makan)= 15cc
c.p cochlear pultis/paribus sendok bubur = 10 cc
c.th. cochlear theae sendok teh = 5 cc
collut.or. collutio oris, collutorium obat kumur (cuci mulut)
collyr collyrium obat cuci mata
d.i.d= da in dim da in dimidio berikan separuhnya
d.c.form. da cum formula tuliskan dengan resepnya
d.d de die sehari
1d.d.=s.d.d semel de die sekali sehari
2 d..d=b.i.d bis de die=bis in die 2 x sehari
3 d.d=t.i.d ter de dir= ter in die 3 x sehari
4 d.d=q.i.d quater de die= quater in die 4 x sehari
dext.et.sin dexter et sinister kanan dan kiri
o.d/o.s. oculus dexter et oculus siniter mata kanan dan mata kiri
d.t.d da tales doses berikan sebanyak dosis tertentu
emuls emulsum emulsi
enem enema lavement
extr. Extractum ekstrak
f fac,fiat,fiant buat, harap dibuatkan
f.la fac lege artis buat menurut cara semestinya
garg. Gargarisma obat kumur
h.m. hora matutina pagi hari
h.s hora somni jam sebelum tidur
inf infusum air rebusan
inj. Injectio obat suntik
iter iteretur 1x harap diulang
iter. 1 x iteretur 1 x harap diulang satu kali
liq. Liquidus cair
lot lotio obat cair untuk obat luar, lotion
m.f misce campurlah & buatlah
m.f.l.a misce fac lege artis buatlah menurut cara semestinya
m.et.v. mane et vespere pagi dan sore
p.p pro paupere untuk si miskin
P.I.M periculum in mora berbahaya bila ditunda
p.r.n pro re nata kalau perlu
pulv. pulvis serbuk ( tunggal )
pulv.adsp. pulvis adspersorius bedak
q.s quantum satis/sulfficit secukupnya
R/ recipe ambillah
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r.p./rec.par recenter paratus dibuat baru

S. Signa tandailah(tulislah aturan pakai)
Sol. Solutio larutan
Spir. Spiritus spiritus/ alcohol 70%
u.c usus cognitus aturan pakai diketahui
u.e. usus externus untuk pemakaian di luar (permukaan tubuh)

Rational Prescribing In Alimentary and Hepatobiliary Disorders

INTRODUCTION

Both alimentary and hepatobiliary are the responsible system for the digestive process and
another for metabolism of many compounds. Certain circumstances of digestive and metabolism
disorders need pharmacotherapeutic approach that must be prescribed as well as rational therapy.
Practical knowledge of prescribing on alimentary and hepatobiliary disorders is required for
medication safety.
Rational prescribing or medication order is choosing the appropriate medication for
alimentary and hepatobiliary by selecting the drug of choice and the dose regimen appropriate to
patients condition, such as: the administration/route, dose, interval or frequency, time, and the
desired plasma concentration. Delivering information on therapeutic plan with colleagues,
pharmacist , whoever will dispense, and nurse, who administer the medication even to the
patients and their family by written, verbal or electronic order are all the important aspect of
successful therapy.
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Rational prescribing is choosing the appropriate medication for alimentary and

hepatobiliary by selecting the administration route, dose, time, and regimen. Delivering
information on therapeutic plan to whoever will administer the medication (written, transcribing,
and verbal) and also to the patients are the important aspect of successful therapy.
Several patients are most at risk of medication error in alimentary and hepatobiliary disorders
such as: use multiple drugs, have another condition (disease, organ failure), cannot communicate
well, have more than drugs, patient who do not take an active role in their own therapy, children
and baby so they need to educate and support comprehensively to prevent the error.

Special Considerations for Alimentary and Hepatobiliary Medication

There are problems may be faced when prescribing drug for alimentary and hepatobiliary
disorders. The major problem related to acidity change that encompasses many simple symptoms
to severe disease. Target specificity is related to pharmacodynamic. Many drugs bind to receptors
or protein selectively and the effect could be agonist (induce) or antagonist (inhibit). Cimetidine,
ranitidine examples of group of H2 receptor antagonist that block acid secretion by parietal cell
are not specific.

The optimum drug therapy is determined by the time of drug administration, duration of therapy,
and appropriate education to the patients aiming for eradicating the bacteria
completelyoptimizing therapeutic outcome. In peptic ulcer disease with infection Helicobacter
pylori that use multiple drugs that may have interaction each other and reduce the drug efficacy,
the time of administration of each drug should be justified. Educate the therapy and how long the
treatment would be ran to eradicate the bacteria without relapse. in chronic diseases.

In constipated patients, drug has been used for long-term treatment as daily treatment but
stopping laxatives too soon. Sometimes treating patients with laxatives: stool softeners (e.g.
mineral oil, glycerin suppositories, and detergent dioctyl sodium sulfosuccinate), bulking agents
(e.g. agar, methylcellulose, lactulose, saline cathartics) and stimulant laxatives (e.g. bisacodyl)
without controlling the success of therapy with follow up.

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Drug, which enterically administered are metabolized rapidly and completely by liver as
first pass effect need dose adjustment because the drug level is decreased suboptimal e.g.
budesonide Keshav, S. 2004. erare problems may be faced when prescribing drug for alimentary
and hepatobiliary disorders. The major problem related to acidity change that encompasses many
simple symptoms to severe disease. The prescriber should be aware when prescribing acid
neutralizing agents (Aluminium hydroxide), sucralfate, proton pump inhibitor (Lanzoprazole,
Omeprazole) for longterm therapy as they can decrease the absorption of several drugs such as
digoxin, fluconazole and also vitamin B12 and Ferrous sulphate which need acidity environment
so prescriber educate that he should take the medicine under supervision.. Also the

The prescriber should educate the patients the information related to duration of therapy
is an important thing becauseas well as he is not allowed to stop therapy when he feel better.
The patient need to remind and warn as a therapeutic goal not just symptomatic relief but also
curing the disease. Antacid should be aware when use more than PPI must be prescribed for 14
days until 2 months and H2 receptor antagonist such as cimetidine, famotidine should not be used
for more than 2 weeks without consulting the clinician, and the should be taken regularly for
prevention relapse.
Timing to administered of medicine could be a determining factor in a suscessfull
therapy. Taking drug before, during, or after meal at spesifc time not just ac, pc, dc may help the
patient to manage their therapy. Examples: Antacid, such as antacid tablet DOEN must be
informed to take by chewing this 30 minutes before meal (ante coenam) or 2 hours after meal
and swollen with plain water. In peptic ulcer disease with infection Helicobacter pylori that use
multiple drugs that may have interaction each other and reduce the drug efficacy, the time of
administration of each drug should be justified. Use PPI such as Omeprazole and Lanzoprazole
as a combination with sucralphate or antacid, or H2receptor antagonist may confuse and potential
interact each other. Educate the patient that H2 receptor antagonists should be taken at night as a
daily dose as food stimulates acid secretion and this may suppress their action.

DAY 2

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P DRUG’s

Some times the drug treatments are the best approach for patient’s problem. Once the
physician decide the patient’s need medicines, he have to make sure that he understand the
patient’s condition, such as: the diagnosis and the pathophysiology implication to the diagnosis
related to the drug’s effect and educate the patient about the medicines.
To facilitate when choosing medicine appropriately, the physician should develop the
own set of P-drugs, personal drug’s that familiar drugs are going to prescribe regularly to the
patients. The P drug’s may differ between physician and country due to variying the availability
and cost also medical culture and individual interpretation of information.

Prescription Prescription or Medication record

There are many medications may be used for alimentary and hepatobiliary disorders. Both
disorders may burden the role of digestive system in detoxifying, lipid, protein, and carbohydrate
metabolism, as well as bile and urea production. Drugs which have adverse effects on
gastrointestinal and hepatobiliary functions must be on mind because both of them must be
protected from potential risk of medication.

Drug Interaction when giving more than 3 drugs concomitantly

How to administered

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Duration of Therapy

Timing to administered

Ac, pc, dc. Antacid, such as antacid tablet DOEN must be informed to take by chewing
this 30 minutes before meal (ante coenam) or 2 hours after meal and swollen with plain water.
PPI such as Omeprazole and Lanzoprazole

Side effect

Prescription or Medication Order Rules

Good prescribing should be based on a series of a rational step that clarifying each of the critical
thinking of drug choice related to patient’s condition as present on figure 1.(Scordo, 2014;
Loftholm, 2012).
Some times the drug treatments are the best approach for patient’s problem,. Once the physician
decide the patient’s need medicines, he have to make sure that he understand the patient’s
condition, such as: the diagnosis and the pathophysiology implication to the diagnosis related to
the drug’s effect and educate the patient about the medicines.
To facilitate when choosing medicine appropriately, the physician should develop the own set of
P-drugs, personal drug’s that familiar drugs are going to prescribe regularly to the patients. The P
drug’s may differ between physician and country due to variying the availability and cost also
medical culture and individual interpretation of information
When Starting a drug treatment, physicians do communication with pharmacist by writing or
typing the drug and the drug regimen comprehensively, continued by monitoring also evaluating
the therapeutic outcomes.

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Patient’s problem

Make spesific
Diagnosis
7. Determine the goal of treatment
7.1 Consider pathophysiologic implication of
the diagnosis
7.2 Select a specific therapeutic objective: Relief
symptoms/ cure/promote/rehabilitation/
preventation
8. Choose a P drug’s
8.1 Take/choose a first choice drug treatment
8.2 Verify appropriateness for the patient
Treatment
9. Start drug treatment
3.4. Write prescription/administer the drug
3.5. Inform, instruct, and warn the patient
3.6. Make next appointment
Result
10. Monitor the result
11. Draw conclusions
Conclusions
6.Determine further action

Further action 8. Stop/alter/continue therapy

Figure 1. Rational Steps when prescribing (Modification from: Loftholm and Katzung,2012)

Prescribing safely preceded by writing the legible prescription or medication order by the
registered prescriber with patient’s full name, specify the body weight in case of children, age,
and full address in good own handwriting, clear verbal or electronic prescription /medication
order. The medication will be written on a prescription form for outpatients or ambulatory care
17
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patients (Figure 2) and the medication order will be written on medication order form or on a
part of patient’s medication record for inpatients or institutional health system such as hospital,
or institutional clinics (Figure 3). Prescription or medication order can be handwritten, typed,
preprinted, verbal, even documented by computer program that is submitted to the pharmacist by
the clinician, patients, or patient’s care giver.

Prescriber’s full address state the accessible prescriber’s address or home base department
completely with active contact number. This information is very important when something
unclear and need any confirmation. Patient’s full name state the patient’s identity with his recent
anthopometric characteristics, such as body weight (kg/lbs), height (m), even body surface area
(m2) for infant and children and also the age. These characteristics determine the specific
quantity or dose of the medicine which is appropriate to patient’s need.

Prescriber must state the drug name using the generic name, the copies of brand-name drugs
which have the same in dosage form, safety, strength, route of administration, quality,
performance characteristics and intended use (from: www.FDA.gov). The drug name were
printed on packaging. Some drugs only available in brand name with patent which protect the
production by the only original manufacture. (Cited from: WHO, 1996; WHO, 2001; Brook, N.
Harris, et al., 2013).

Patient’s problem

Make spesific
Diagnosis
12. Determine the goal of treatment
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12.1 Consider pathophysiologic implication of

the diagnosis
12.2 Select a specific therapeutic objective:
Relief symptoms/
cure/promote/rehabilitation/ preventation
13. Choose a drug treatment
13.1 Take/choose a first choice drug treatment
13.2 Verify appropriateness for the patient
Treatment
14. Start drug treatment
3.7. Write prescription/administer the drug
3.8. Inform, instruct, and warn the patient
3.9. Make next appointment
Result
15. Monitor the result
16. Draw conclusions
Conclusions
6.Determine further action

Further action 9. Stop/alter/continue therapy

Figure 1. Rational Steps when prescribing (Modification from: Loftholm and Katzung,2012)

Prescribing safely preceded by writing the legible prescription or medication order by the
registered prescriber with patient’s full name, specify the body weight in case of children, age,
and full address in good own handwriting, clear verbal or electronic prescription /medication
order. The medication will be written on a prescription form for outpatients or ambulatory care
patients (Figure 21) and the medication order will be written on medication order form or on a
part of patient’s medication record for inpatients or institutional health system such as hospital,
or institutional clinics (Figure 32). Prescription or medication order can be handwritten, typed,
preprinted, verbal, even documented by computer program that is submitted to the pharmacist by
the clinician, patients, or patient’s care giver.

Prescriber’s full address state the accessible prescriber’s address or home base department
completely with active contact number. This information is very important when something
unclear and need any confirmation. Patient’s full name state the patient’s identity with his recent
anthopometric characteristics, such as body weight (kg/lbs), height (m), even body surface area
(m2) for infant and children and also the age. These characteristics determine the specific
quantity or dose of the medicine which is appropriate to patient’s need.
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Prescriber must state the drug name using the generic name, the copies of brand-name drugs
which have the same in dosage form, safety, strength, route of administration, quality,
performance characteristics and intended use (from: www.FDA.gov). The drug name were
printed on packaging. Some drugs only available in brand name with patent which protect the
production by the only original manufacture. Medications should be prescribed only when the
treatments following clear diagnosis while considering the risk for special population such as
neonates, pregnancy, elderly, renal, and liver disorders. The prescriber must write the prescribing
written legibly in ink with patient’s full name, specify the body weight in case of children, age,
and full address in clear handwriting.

 State the Drug Name using the generic name which were printed on the packaging. Some drugs
only available in brand name with patent. Do not use abbreviations except the drug has been
popular with the name due to risk of misinterpretation.

 Drug dosage form, unit dose must be written as a word, avoid using symbol. Do not use
unnecessary decimal points to state unit weight, volume, or specific unit (IU) and also must be
careful when positioning zero “O” in the front with points. Actually zero “0” is unnecessary and
confusion.

 Write the frequency/interval drug’s use in numerals and Roman such as 3 dd I or state in terms of
hours e.g. 8 hourly or every 8 hours. In the case of “as required” or prn, the minimum dose
interval should be spesified. Time consuming of the drug state in ante coenam or “a.c”. for
before meal; durante coenam “d.c.” while meal time, post coenam “p.c.” for after meal. The time
could be stated in specific time for special drugs, so it must be written clearly. The patients who
are following chronic therapy or repeated treatment must be stated on the prescription with iter
1x, iter 2x.

 In the case of emergency state “urgent”, “STATIM” or “CITO” with aposthrof “!” in the blank
area where read easily.

 The dose strength must be written as state on the package, e.g. 250mg/5mL. The total quantity of
medicines were described the length of therapy in Roman. State and write clearly the preparation
method, use or consume of the medicine to get the optimum effect exactly.

 Sign and date at the end of session of prescribe on the script. Check the name,dose, dose unit,
route, frequency/interval, duration of each item to confirm any over /sub optimal dose,
redundancy, and potential interaction. Finally, check prescriber identity, telephone number and
the attribute to facilitate when something unclear.

(Cited from: WHO, 1996; WHO, 2001; Brook, N. Harris, et al., 2013)

dr Nyoman Cermat
SIP:......
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Praktek Jl….
No Telp. HP….
…………….,……………………
R/ Drug name Obat..Potency..Unit…Dosage form…
packaging..Amount…No…
Signa………

……………………………………………..ttd

Pro:…
Umur: ……. BB:…Kg
Alamat:

Figure 2. Prescription Form

RM.11.2/OBAT/2015
Nama :
L/P :
CATATAN PENGOBATAN Umur :
Berat Badan :
OBAT No RM :
Alergi :

Tgl. Nama Obat Rute Aturan Pakai

Mulai & Dosis

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Indikasi ROTD
Tgl.
Stop Paraf (nama dokter )
Catatan

Figure 3 Medication Record Form

REFERENCES
OSCE’s for Medical Students, Volume 2, 2nd . edition. PasTest. edition cited from: http: www.
um.es>document_library>get_file
Broek, N. Harris, M. M. Henkens, H. Mekaoui, Palma, E. Szumilin. V. Grouzard N. 2013.
Clinical Guidelines. Diagnosis and Treatment manual. for curative programmes in hospitals and
dispensaries. Guidance for prescribing
McQuaid, K.R. 2012. Drugs Used in Treatment of Gastrointestinal Diseases. (Keshav, S. 2004.
Pharmacotherapy. In: The gastrointestinal System at a Glance. Blackwell Science Ltd.p.104-5.
Editors: Katzung, B., Masters, S.B., Trevor, A.J. In: Basic and Clinical Pharmacology. 12th
edition. Chapter 62. 12th edition ). Mc Graw Hill. New York. P 11081-1114.
Lofholm, P. Katzung, B. 2012. Rational Prescribing & Prescription Writing (Editors: Katzung,
B., Masters, S.B., Trevor, A.J. In: Basic and Clinical Pharmacology. 12 th edition. Chapter 65. ).
Mc Graw Hill. New York. P 1139081-1114.

Kepmenkes RI No 312/Menkes/SK/ IX/2013 tentang Daftar Obat Essensial Nasional 2013

Permenkes RI No 5 tahun 2014 tentang Panduan Praktik Klinis Bagi Dokter Di Fasilitas
Pelayanan Kesehatan Primer.
Koda-Kimble, M.A; Young, L.Y; Alldredge, B.K.; Corelli, R.L., Guglielmo, B.J; Kradjan, W.A;
Williams, B.R. 2009 Applied Therapeutics. The Clinical Use of Drugs 9th edition. Lippincott
William & Wilkins.
Scordo, K.A. 2014. Teaching Student about the WHO Guide to Good Prescribing. The Nurse
Practitiioner. Lippincott, Wiliams & Wilkins.
Jones, O; Gautam, N. 2004. The hands-on guide to practical prescribing. Blackwell Publishing.

22
 23

WHO , 1996. Guide to Good Prescribing Geneva

23
 TTRAINING DAY 1

Scenario

1. Lenny (37 yo) experienced to epigastric pain or discomfort located primarily in the upper abdomen following hot meals
accompanied by stomach ache, acid regurgitation, burning sensation, nausea.

a) Describe your clinical findings and relate them to the underlying pathophysiology.

b) What is your advice regarding her complaint?

1
 2

c) She show the prescription to you. Analyze this prescription rationally including the rational prescribing step (see below).

d) She told you she was afraid about the side effect of the medicine as she always get it from nonprescription. How would you
reply to this statement? (Include evidence base for all your answers)

dr X
SIP: ......
Praktek Jl….
No Telp. HP….
Denpasar, 20 Maret 2019
R/ Antacida DOEN chewable tablet No X
S 3 d d tab I p.c

R/ Famotidine 40mg Tab. No X

S 1 d d tab I ac
R/ Omeprazole 20mg caps No VI
S 2 d d cap I

Pro : Leny
Umur : 37 tahun BB: 55kg
Alamat : Jl Kamboja 2, Dps

2. Mr Yuna 47 years old went to the emergency unit at 10.30 pm, complained hot and burning sensation in epigastric. He was very
worried about his heart burn and stressed. He told that he toke antacid but he felt it did not work well. The symptom worse in the
evening when he lied down in supine position. He already had drank coffee and had big dinner. Do the rational prescribing
following the rational step and write the medication order on the medication record below.

2
 3

RM…./OBAT/2016
Nama :
L/P :
CATATAN PENGOBATAN Umur :
Berat Badan :
No RM :
OBAT Alergi

Tgl. Nama Rute Aturan

Mulai Obat & Pakai
Dosis
Indikasi ROTD
Tgl.
Stop Paraf (nama
Catatan dokter )

Tgl. Nama Rute Aturan

Mulai Obat & Pakai
Dosis
Indikasi ROTD
Tgl.
Stop Paraf (nama
Catatan dokter )

3
 4

3. Please answer the following questions regarding the rational drug by indicating whether the statements are True or False.

a. Epigastric pain or discomfort located primarily in the upper abdomen following meals, often accompanied by bloating, nausea and
fullness sensation spontaneous.

No Statement True False

1 Short term symptomatic Metoclopramide PO 30mg/day in 3 divided
doses given 6 hours apart, ½ hour before meals for 2 to3 days.
2 Hyocine butylbromide PO 30mg/day in 3 divide doses, ½ hour
before meals for 2 to3 days for spasmodic pain.

b. Associated with burning stomachache, heartburn, acid regurgitation while sitting.

No Statement True False

1 Al (OH)3 po 1.5 to 3g/day in 3 divided doses one hour after meals
2 Al hydroxide 500mg at the time of a painful attack
3 Do not take Al (OH)3 at the same time, interval at least 2 hours
between PPi when antacids are insufficient.
4 Omeprazole po 20mg once daily mane for 3 days
5 Cimetidine P.O 400mg once daily at bedtime for 3days

c. Which are associated with burning epigastric pain and epigastric cramps complaint between meals, wake the patient at night. They occurred
as episodes when having late lunch and stressed accompanied by nausea and even vomiting.

No Statement True False

1 NSAID or Acetylsalicylic acid could be an inducer
2 PPi is recommended
3 Omeprazole p.o: 20mg once daily in the morning for 7 to 10 days
4 Cimetidine P.O 800mg once daily at bedtime for 7-10 days

4
 5

If the patient has frequent attacks and proven micrositic anaemia, diagnosed as Helycobacter pylori infection.

No Statement True False

1 The patient may require triple therapy (metronidazole PO 1g/day in
2 divided doses+amoxicillin PO 2g/day in divide
doses+omeprazole po 40mg/day in divided doses)
2 Triple therapy is given for 3 to 4 weeks
3 Clarithromycin is commonly used in triple therapy
4 Clarithromycin + Amoxicillin 1g
5 Cimetidine is a proton pump inhibitor used in triple therapy
1600mg/day in divided doses
6 Bismuth subcitrate po 480mg/day in 4 divided doses as an anti
ulcer
7 drugs
8 This patient will need to be on routine omeprazole for life
Aspirin and NSAID (Indometacin, Ibuprofen, diclofenac are
contra-indicated

d. Which are associated with Sita 4,5 years old, a kindergarten come to physician accompanying by her mom yesterday afternoon. She
experienced vomiting, liquid stools 3 times since in the morning after taking ice stick. Axial temperature was 370C.

No Statement True False

1 Oral rehydration as required until the diarrhea stops
2 Administer Zinc sulphate 20mg once daily for10 days
3 Do not administer Antiemetic
4 Do not administerAnti-diarrhoeal drugs

TRAINING DAY 2

P DRUG’s

5
 6

Scenario:

1.

2. LEARNING TASK

3. Develop P Drug’s for Alimentary and Hepatobiliary Disorders refer to Permenkes RI Nomor 5 tahun 2014, Panduan Praktik
Klinis bagi Dokter di Fasilitas Pelayanan Kesehatan Primer and McQuaid, K Drug Used in the treatment of Gastrointestinal
Diseases (In: Katzung, Bn(Editor) Basic and Clinical Pharmacology or MIMS on line. Fill in the blank area with drug, dose
regiment appropriately in excel file enclosed.

4. Problem Solving

a. .Mr Heru 75 years old experienced abdominal discomfort. He told that he observed blood in the stool. He also had back
pain which may reduce his mobility as he frail. Develop P drug’s for him if it is related to the constipation.

b. An infant, 11 month boy suffering from inflammation of the mucous membranes of the mouth and also there is white
patches on the tongue, inside of the cheek and painful. She experienced difficulties in sucking and refused to breastfeed.
Develop the P drugs if it is related to oral candidiasis Choose the appropriate medice and write the complete prescription
below.

c.

No DIGESTIVE Drug of Dose Regiment Others

Choice
(Dose, Dosage form,
1st Interval/Frequency,
choice/2nd Duration)
choice

1 Refluks gastroesofageal

6
 7

No ICPC II: D84 Oesophahus

disease
No. ICD X: K21.9 GERD
without oesophagitis

2 Gastritis
No. ICPC II: D07
Dyspepsia/indigestion
No. ICD X: K29.7 Gastritis,
unspecified

3 Intoleransi Makanan
No. ICPC II: D29 Digestive
Syndrome/complaint other
No. ICD:

4 Malabsorpsi Makanan
No. ICPC II: D29 Digestive
Syndrome/complaint other
No. ICD:

5 Demam Tifoid
No. ICPC II: D70
Gastrointestinal infection
No. ICD: A01.0. Thyphoid Fever

6 Gastroenteritis (include

7
 8

Dysentri, cholera, and giardiasis

No.ICPC II: D73 Gastroenteritis
presumed infection
No. ICD: A09 Diarrhoea and
gastroenteritis of presumed
infection origin

7 Disentri Basiler dan Disentri

amuba
No. ICPC II: D70
Gastrointestinal infection
No. ICD X:

8 Apendisitis akut
No. ICPC II: S87 (Apendicitis)
No. ICD X: K.35.9 (Acute
appendicitis)

9 Perdarahan Saluran Makan

Bagian Atas
No. ICPC II: D14
Haematemesis/vomiting blood
D15 Melaena
No. ICD X:
Lesi korosif esofagus

8
 9

10 Hemoroid 1-2
No.ICPC II: D95 Anal
fissure/perianal abscess
No. ICD X:

11 Hepatitis A
No. ICPC II: D72 Viral Hepatitis
No ICD X:

12 Kolesistitis
No. ICPC II: D98
Cholecystitis/cholelithiasis
No ICD X: K81.9. Cholecystitis,
unspecified

9
d. Scenario

e. 1. Mr Heru 75 years old experienced abdominal discomfort. He told that he observed blood in
the stool. He also had back pain which may reduce his mobility as he frail. He has been taking
dihydrocodeine for 3 days. Do you think he need other medication?

2. An infant, 11 month boy suffering from inflammation of the mucous membranes of the mouth
and also there is white patches on the tongue, inside of the cheek , and painful. She experienced
difficulties in sucking and refused to breastfeed. Choose the appropriate medice and wWrite the
complete prescription below.

dr
SIP:......
Praktek Jl….
No Telp. HP….
…………….,……………………
R/

……………………………………………..ttd

Pro:…
Umur: ……. BB:…Kg
Alamat:

NOTE: (This self assessment is modified from: Brook, N,Harris, et.al. 2013, Keshav, F, 2004 ,
Koda-Kimble, 2013, Permenkes RI no 5, 2014)

3.

1
 2

f. Mr Yuna 47 years old went to the emergency unit at 10.30 pm, complained hot and
burning sensation in epigastric. He was very worried about his heart burn and
stressed. He told that he toke antacid but he felt it did not work well. The symptom
worse in the evening when he lied down in supine position. He already had drank
coffee and had big dinner. What is your advice and drug treatment for him and use
the medication record below.prescription form below.

dr Nyoman Cermat
SIP:......
Praktek Jl….
No Telp. HP….
…………….,……………………
R/ Drug name Obat..Potency..Unit…Dosage form…packaging..Amount…
No…
Signa………

……………………………………………..ttd

Pro:…
Umur: ……. BB:…Kg
Alamat:

RM…./OBAT/2016
Nama :
L/P :
CATATAN PENGOBATAN Umur :
Berat Badan :
No RM :
OBAT Alergi

Tgl. Rute Aturan Pakai

2
 3

Mulai Nama Obat

& Dosis
Indikasi ROTD
Tgl.
Stop Paraf (nama dokter )
Catatan

Tgl. Nama Rute Aturan Pakai

Mulai Obat &
Dosis
Indikasi ROTD
Tgl.
Stop Paraf (nama dokter )
Catatan

SUPPLEMENT

Prescribing Skills Assessment

3
 4

Score (Tanda V)
Item Komponen Resep Score Resep Resep Resep
1 2 3

1 Tanda R/ 5

2 Nama obat 15

Bentuk sediaan 10

Dosis 15

Jumlah obat yang diminta

10
(durasi terapi)

Signatura

3 Cara penggunaan dan 5

petunjuk khusus (ac, pc,
dc, prn.)

Frekuensi penggunaan
10
sehari

4 Paraf/Tanda tngan 5

5 Tanda tutup resep 5

Identitas pasien (Nama

6 10
Pasien)

7 Umur/berat badan/LPT 10

Total Score

Nilai Akhir = (R1 + R2 + R3) / 3 =

Figure 12. Prescription Form

4
 5

RS UNIVERSITAS UDAYANA RM.11.2/OBAT/2015

Nama : L/P
:
CATATAN PENGOBATAN Umur : Berat
Badan :

OBAT No RM :
Alergi :

Tgl. Nama Obat Rute Aturan Pakai

& Dosis
Mulai
Indikasi ROTD

Tgl.

Stop Paraf (nama dokter )

Catatan

5
 6

REFERENCES

OSCE’s for Medical Students, Volume 2, 2nd edition cited from: http: www.
Broek, N. Harris, M. M. Henkens, H. Mekaoui, Palma, E. Szumilin. V. Grouzard N. 2013.
Clinical Guidelines. Diagnosis and Treatment manual. for curative programmes in hospitals and
dispensaries. Guidance for prescribing
Keshav, S. 2004. Pharmacotherapy. In: The gastrointestinal System at a Glance. Blackwell
Science Ltd.p.104-5.
Kepmenkes RI No 312/Menkes/SK/IX/2013 tentang Daftar Obat Essensial Nasional 2013
Permenkes RI No 5 tahun 2014 tentang Panduan Praktik Klinis Bagi Dokter Di Fasilitas
Pelayanan Kesehatan Primer.
Koda-Kimble, M.A; Young, L.Y; Alldredge, B.K.; Corelli, R.L., Guglielmo, B.J; Kradjan, W.A;
Williams, B.R. 2009 Applied Therapeutics. The Clinical Use of Drugs 9th edition. Lippincott
William & Wilkins.
Jones, O; Gautam, N. 2004. The hands-on guide to practical prescribing. Blackwell Publishing.
WHO , 1996. Guide to Good Prescribing Geneva
WHO, 2001. Teacher’s Guide to Good Prescribing. Department of Essentials Drug and
Medicines Policy. France

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