You are a Family Nurse Practitioner employed in a busy prima

You are a Family Nurse Practitioner employed in a busy primary care office. The providers in the group include one physician and three nurse practitioners. The back office staff includes eight medical assistants who assist with patient care as well as filing, answering calls from patients, processing laboratory results and taking prescription renewal requests from patients and pharmacies. Stephanie, a medical assistant, has worked in the practice for 10 years and is very proficient at her job. She knows almost every patient in the practice, and has an excellent rapport with all of the providers.

Mrs. Smith was seen today in the office for an annual physical. Her last appointment was a year ago for the same reason. During this visit, Mrs. Smith brought an empty bottle of Amoxicillin with her and asked if she could have a refill. You noted the patient’s name on the label and the date on the bottle was one week ago. You also noted your name printed on the label as the prescriber. The patient admitted that she called last week concerned about her cough and spoke to Stephanie. You do not recall having discussed this patient with Stephanie, nor do the other providers in the practice.

Discussion Question:



What is your next logically sound course of action? Provide evidence to support your response.

Solution

Answer:

The care of the patient is most important. It is your responsibility as the provider to perform a thorough and accurate history and examination to help diagnose the patient in order to determine the best course of treatment. Cough can be due to many things (throat irritation, viral infections, bacterial infections, etc.), not all of which require antibiotics as treatment. In Martin Blaser\'s 2011 article (linked here: http://www.nature.com/nature/journal/v476/n7361/full/476393a.html) he discusses antibiotic overuse. Many patients come to providers with cold symptoms, including cough, asking for and expecting antibiotics, when in many of these cases, antibiotics are not warranted because they do not help the patient, but instead, promote the development of bacterial resistance. As such, it would be highly inappropriate to simply fill out the prescription for amoxicillin (unclear if the patient needs antibiotics without proper diagnosis, or if amoxicillin is the correct antibiotic).

Secondly, it is important to address how Mrs. Smith received the bottle with the recent date, especially given that she had not come to the practice in one year. Stephanie is a medical assistant and although proficient, does not have the medical knowledge, or capacity to write prescriptions. It would be dangerous for her to make medical decisions for patients, and from a legal standpoint be harmful for the practice.

It would be important to speak to Stephanie at some point to see how she came up with the prescription and why she did so, since she did not discuss this with any provider (who would be capable of medical decision making).