Definition

For medicines, the Royal Pharmaceutical Society (RPS) and the Royal College of Nurses (RCN) define transcribing as the accurate copying of previously prescribed medicines details to enable their administration in line with legislation (i.e. in accordance with the instructions of a prescriber).

Legislation

There is no direct legislation on transcribing. However, legislation does cover administration under the direction of a prescriber and the Medicines and Healthcare products Regulatory Agency (MHRA) has advised that a direction to administer needs to be in writing for a Prescription Only Medicine (POM).

Record keeping

All healthcare professionals are required to keep contemporaneous records of their activities to:

• ensure an auditable trail of activity related to the patient
• protect both the organisation and the individual in the case of enquiry or litigation

Particularly for medicines administration, accurate records are expected to be kept for all medicines (including those administered as a result of transcribing).

Healthcare staff able to transcribe

As the term does not have a legal status, transcribing can be carried out by any trained and competent individual.

When transcribed information cannot be used legally

Transcribing is the exact copying of medicines details for the purposes of administration only.

It cannot be used:

• in place of prescribing
• to supply or dispense medicines
• to add new medicines
• to alter or change original prescriptions.

For example, if information is transcribed on to a chart it cannot be used as a prescription to supply medicines to a patient or to a healthcare setting, unless the chart is counter-signed by a prescriber.

Organisations must ensure that they have safeguards to prevent transcribed information being inadvertently used as a prescription.

Organisational policies and procedures

Robust policies and procedures are needed to underpin organisational decisions to implement transcribing in practice. Such policies need to be clear about when transcribing can be used and in which settings and ensure the following points are covered.

Risk assessments

Policies and procedures should detail the requirements of the underpinning risk assessment.

Training

Organisations must ensure that those undertaking transcribing are identified and appropriately trained and assessed as competent to do so.

Transcription process

The policy must define how and where the transcriber signs the chart after undertaking transcribing and where organisations deem that a second check is required, this must be detailed and under what circumstances.

Transcription for Prescription

Where a transcribed chart may subsequently require a counter-signature by a prescriber so that it can be used to supply medicines to a named patient, organisations need to detail this within their policy.

Errors

The policy should define the procedure for dealing with errors in transcribed information.

Non-medical prescribers

Where a non-medical prescriber is transcribing because prescribing would be outside their scope of prescribing practice, organisations may need to consider the need for further training, if appropriate.