Ref. No.
(Unique Identi er)
Clinic Name
Address and Contact Information
Doctor Name
Quali cation:
Specialization:
PM&DC Reg. No.0000-P
PHC Reg. No. XXXXXXX PHC RL. No. XXXXXXX
ا ج
Patient Name S/o, D/o, W/o
No. of Visit Time Date/s
Address Contact No.
B.P Age Gender Weight (kg)
Pulse Provisional/Diagnosis
Temperature
RR
Rx
Allergies
Presenting Complaints
History
Findings
Investigations
DISPENSING STAMP (Signature & Stamp)
Re ll 0 1 2 3 4 Contact Number (Optional)
Clinic days & timings : dd to dd, 00:00 to 00:00
Ref. No. (Unique Identi er)
Clinic Name
Address and Contact Information
Doctor Name
Quali cation:
Specialization:
PM&DC Reg. No.0000-P
PHC Reg. No. XXXXXXX PHC RL. No. XXXXXXX
ا ج
Patient Name S/o, D/o, W/o
No. of Visit Time Date/s
Address Contact No.
B.P Age Gender Weight (kg)
Pulse Provisional/Diagnosis
Temperature
RR
Rx
Allergies
Presenting Complaints
PRINTABLE VERSION
History
Findings
Investigations
DISPENSING STAMP (Signature & Stamp)
Re ll 0 1 2 3 4 Contact Number (Optional)
Clinic days & timings : dd to dd, 00:00 to 00:00
⁸Ref. No. (Unique Identi er)
1
Clinic Name
Address and Contact Information
⁶Doctor Name
⁷Quali cation:
Specialisation:
9
PM&DC Reg. No.0000-P
⁴PHC Reg. No. XXXXXXX ⁵PHC RL. No. XXXXXXX 10
ا ج
11
Patient Name S/o, D/o, W/o
No. of Visit Time Date/s
Address Contact No.
12 13
B.P Age Gender Weight (kg)
Pulse Provisional/Diagnosis
14-16
Temperature
RR
Rx
Allergies
Presenting Complaints
GUIDANCE VERSION
History
Findings
Investigations
18
17
DISPENSING STAMP (Signature & Stamp)
19 20
Re ll 0 1 2 3 4 Contact Number (Optional)
Clinic days & timings : dd to dd, 00:00 to 00:00
Components of the Prescription Template
1. Clinic Name: Name of the HCE as registered 6. Doctor Name: As per PHC / PM&DC registration of 8. Ref. No. (Unique identifier): Represents the
with PHC the healthcare provider prescription’s unique number series maintained
2. Address and contact information: as by the HCE
registered with PHC 7. Qualification/Specialization: Only PM&DC
approved qualification 9. QR code: QR code printed on the HCE’s
3. PM&DC Reg. No.: As per the PM&DC registration certificate issued by the PHC and
registration certificate of the clinician(s) Should be inline with approved qualification, easily may be used to determine the authenticity HCE’s
understandable with clear titles and must not be details by the patients and pharmacy staff
4. PHC Reg. No.: As per the PHC registration misleading
certificate of the HCE 10.: ا ج PHC slogan to be
5. PHC RL No.: Regular license number issued printed to promote practice qualified practitioner
to the HCE by the PHC and curb quackery
Grey Highlighted Area (patient’s details)
11- Patient Name: Complete name of the patient S/o, D/o, W/o: Patient’s father name to be written for Son of (S/o), Daughter of (D/o) and husband’s name to be
written for wife of (W/o) No. of Visit: Number of patient’s visit to the HCE (1st, 2nd, or 3rd etc.)
Time: Time of visit at the HCE Date/s: Date of the visit Address: Address of the patient Contact No.: Contact number of the patient
12. Vitals (BP, pulse, temp. and RR 13. Patient’s age, gender, weight (mandatory for
(respiratory rate)), allergies, presenting
complaints, history, findings and investigations:
pediatric patients) and provisional diagnosis Guidance for Using Standard
prescribers are advised to note down the
Rx Prescription Template
necessary clinical details
Guidance for prescription writing to be followed Prescriptions must always be
for each medicine:
written in a de nite pattern,
14. Line 1. Dosage form (Tab, Inj, Syp, Lotion etc,
name of the medication (preferably both generic and following a standard and universal
BRAND name), strength of the medication (e.g., 500 arrangement, to ensure uniformity.
mg, 2.5 mg/ml),
15. Line 2. Instruction include the quantity of
medicine to be taken at one time followed by route of The information should be
administration (orally, topically, intravenously, intra
muscular), frequency of administration (every 24
complete, accurate and
hours, every 8 hours etc.) and duration of treatment unambiguous. Hence it should be
(for 7 days, continue till further advice)
legible and clearly written without
16. Line 3. Prescribers are advised to also provide,
any other instructions or caution to the patient e-g any abbreviations.
"take with food," "avoid driving, take at night" and
when to discontinue medicine and report back.
Note: Prescription may also include advice on life
style changes like diet, exercise etc. in quantifiable
terms like take 8 glasses of water daily or 30 minutes
of daily walk for 3 days a week.
18. Dispensing Stamp: It is required to be
affixed by the pharmacy / medical store after
dispensing of the prescription. Once
dispensed, prescription can only be refilled
according to the refill instructions provided by 17. Stamp to be placed below the clinician’s
the clinician under the refills heading. signatures
19. Refills: Prescription refill means, number of time one can get new supply of the prescribed medication 20. Contact number of HCE / Clinician to be written
without revisiting the prescriber. It is defined by the prescriber at the time of the prescription writing if (optional) along with clinic days and timings.
needed. When marked "0" it means no refills are permitted by the prescriber and re-dispensing on the
same prescription will not be allowed. This provision is important in case of steroid, narcotics, antibiotics,
tranquilizers, sedatives etc. to safeguard the patients.
