SigText

14 min

SigText Field Best Practices

Use a Sig Builder

✅ Quality Check - Use a Sig Builder: Ensure the vast majority of patient directions are created using a standardized SIG composition function whenever possible.

Clinical Relevance/Rationale:

The utilization of a SIG builder is an important step in the creation of a high quality, repeatable SIG. Use of a SIG builder ensures variability in patient directions is reduced as the directions are inserted by the system in the same format each time. This helps ensure all needed elements are present and reduces the amount of human manipulation needed thereby reducing the overall risk of an adverse drug event.

Best Practices - For Technology Partners:

Implement a robust, default Sig-builder tool to help end users construct high quality, repeatable directions from comprehensive usability testing.

There will be a limited number of instructions that even a complex Sig-builder cannot accommodate. In these cases, allow end users to enter free-text, custom patient instructions. If free text must be used for more complex directions, consider clearing out the pre-populated Sig to avoid possible conflicting information.

Ensure Sig Directions are Complete and Accurate

✅ Quality Checks - Ensure Sig Directions are Complete and Accurate: Ensure all information in the patient directions or SigText field is clinically correct and complete, with all the required components written in the same order as listed below (i.e., action, dose, dose units, route, frequency, and auxiliary information). Ensure information in the SigText field is not unnecessarily repeated nor conflicts with any other field of the e-prescription.

Examples:

Use “Take 1 tablet by mouth daily” instead of just “Daily.”

Use “Take 1-2 tablets by mouth daily as needed for pain” instead of “1 PO QD. Take 1-2 tablets as needed for pain.”

Use “Take 1 capsule (40 mg) by mouth daily” instead of “Take 1 capsule (40 mg total) by mouth once daily Take 2 capsules (80mg total) by mouth once daily.

Clinical Relevance/Rationale:

Since directions contain the information for patient use of a drug/therapy, it is critical that the information be accurate, complete, and unambiguous. The use of a Structured and Codified Sig standardizes the structure and syntax of the prescriber’s directions to the dispensing pharmacist and patient, thereby reducing the opportunity for misinterpretation of the prescriber’s intent.

If the patient instructions are vague, ambiguous or in conflict with information elsewhere in the transaction, it will be necessary to contact the prescriber for clarification. This creates workflow disruptions for pharmacies and prescribers alike. Moreover, if such conflicts result in misinterpretation and incorrect directions on the prescription label, they can threaten patient safety.

Best Practices - For Technology Partners:

Ensure the SIG builder provides all needed elements in the composed SIG.

Using compendia sourced information, when possible, prepopulate or provide the user with the “action”, “dose unit”, and “route” based on the drug selected.

If the end user is unable to convey the complete and accurate instructions with the SIG builder, allow the prescriber to opt out of the standardized Sig and create a completely custom Sig.

To improve efficiency, allow end users to save favorite, properly formatted Sig strings for future use.

Construct the final patient directions using any discrete elements from a Sig-builder in the normal Sig pattern: action, dose, dose unit, route, frequency. Avoid delineators in the final directions.

Always clearly display the final fully constructed Sig to the end user prior to transmission.

Best Practices - For Prescribers:

Save the most commonly written Sigs, including tapered doses and other complex regimens.

Ensure that the Sig is constructed with all essential elements in the appropriate order so the patient directions will be clearly understood.

Never Truncate or Split Directions

✅ Quality Checks - Never Truncate or Split Directions: While the NCPDP limit is 1000 characters, some applications are developed to support fewer. In either instance, patient directions should not overflow into the Notes field. If patient directions are being transmitted in an unstructured way and they exceed character limits, then communicate by other means, such as by faxing the information to the pharmacy or printing out and providing the instructions to the patient.

Clinical Relevance/Rationale:

The receipt of incomplete patient directions prevents the pharmacist from performing clinical checks. More importantly, the pharmacist will not be able to fully counsel the patient on how to take/use their medication. Or the pharmacist may provide information to the patient that conflicts with the prescriber’s recommendation. This can lead to patient confusion and possible medication errors.

Best Practices - For Technology Partners:

Warn end users when the character count nears or exceeds the defined character limits. Consider replacing directions that exceed character limits with “take as directed per physician written instructions” and develop workflow(s) to educate patients about the instructions and/or provide printed copies of the directions.

Create default directions that are less than the character limits for commonly prescribed lengthy patient directions, such as tapered doses and titrations. For example, for a 60 mg prednisone taper using 10 mg tablets write, “Take 6 tabs orally daily for 2 days, 5 tabs daily for 2 days, 4 tabs daily for 2 days, continue to decrease by 1 tab every 2 days until gone.”

Contains Only Patient Directions

✅ Quality Checks - Contains Only Patient Directions: Ensure the SigText field only contains information relating to the patient directions. Do not include information for which another designated field exists in the SCRIPT standard (e.g., ensure the patient directions never include the quantity, drug name, refills, NDC or RxCUI values, etc.).

Example:

Use “Take 1 tablet by mouth once daily” instead of “Take 1 tablet by mouth once daily, #30 3 Refills.”

Clinical Relevance/Rationale:

Many clinical decision support tools leverage the e-prescription’s discrete data fields and rely on specific types of information being entered in the correct designated fields intended to accommodate it. Thus, only patient directions are to be entered in the SigText field to optimize the benefits from the decision support tools as well as improve the overall quality of the e-prescription.

Use Structured and Codified Sig

✅ Quality Checks - Use Structured and Codified Sig: Send patient directions in a structured and codified manner following the SCRIPT standard.

Clinical Relevance/Rationale:

Adoption of Structured and Codified Sig minimizes ambiguity and assists in the standardization of Sigs in effort to avoid the possibility of inaccurate translation by the receiving partner. Standardization minimizes permutations, facilitates accuracy, promotes patient safety, and improves efficiency. Standardized, structured data reduces the potential for transcription errors and enables automated monitoring of quality metrics. When prescription directions are transmitted using a structured data format and standard terminologies, the meaning is preserved in a system-processable form. Because the clinical components such as route of administration and administration timing are represented as standardized terms, every receiving system will interpret the information in the same way. Moreover, each receiver can map the Sig components to its internal data structures to support clinical alerts, dispensing automation, or other processing.

Best Practices - For Technology Partners:

When initiating implementation of Structured and Codified Sig, determine the 100 most common Sig concepts and make sure the system can fully accommodate the construction and transmission of these Sig strings. Develop system enhancements to accommodate the codification of less frequently used Sigs.

Ensure the code systems remain up-to-date with newly published versions of SNOMED CT® and FMT code sets. It is recommended that the most recent version of the code system be used.

Send an Indication

✅ Quality Checks - Send an Indication: Including an indication in patient directions is strongly recommended. The indication is a statement of the reason or therapeutic objective for the prescribed medication. Only use “PRN” (i.e., “as needed”) in conjunction with an indication or intended therapeutic objective.

Note: The use of an indication does not replace the use of the Diagnosis segment, which remains separate and is to be completed whether an indication is added to the patient directions or not.

Examples:

Use “Take 1 tablet by mouth every 4 hours as needed for mild to moderate pain.”

Use “Use according to instructions on dose pack for poison ivy rash.”

Clinical Relevance/Rationale:

The inclusion of indications is helpful to patients, pharmacists, and other prescribers. Including indications on prescriptions helps patients better understand and manage their medications. Pharmacists use indications when counseling patients and to help ensure the correct drugs have been prescribed. Prescribers may find indications helpful when they see patients who have been or are concurrently being treated by other prescribers.

Using PRN without any added information assumes the patient or caretaker fully understands and remembers what the direction “as needed” signifies. This understanding may not exist or may be very short-lived. Without the full indication, PRN provides little to no additional information upon which the pharmacist can base patient counseling, thus it can lead to incorrect and possibly unsafe use by the patient.

Best Practices - For Technology Partners:

If the Sig-builder tool is used, ensure that it requires end users to enter the specific indication or conditions for PRN use if the prescriber selects a PRN frequency.

Best Practices - For Prescribers:

Enter the indication into the Sig whenever possible to help the patient and the pharmacist fully understand the intended use of the medication.

Take as Directed

✅ Quality Checks - Take as Directed: Qualify the use of statements such as “Take as directed” and “Use as instructed” to clearly dictate where or from whom the patient can obtain the specific directions.

Examples:

Use “Inject subcutaneously as directed per sliding scale provided by physician” instead of “Inject as directed.”

Use “Use as instructed per instructions on package” instead of “Use as instructed.”

Clinical Relevance/Rationale:

Using a Sig such as “Take as directed” without referencing the source of the instructions, may cause confusion for the patient regarding the medication dosage, route, or frequency. Vague instructions can lead to a patient-safety risk due to incorrect and unsafe medication usage.

Best Practices - For Technology Partners:

If a Sig-builder tool is used, ensure that it requires end users to enter the specific source of the instruction after selecting the “Take/use as directed/instructed” option before they can finalize the transaction.

Best Practices - For Prescribers:

Limit the use of these statements to specific scenarios when a set of instructions is clearly provided to the patient and/or caretaker.

When entering “Take/use as directed/instructed,” make sure the specific source of the directions/instructions is made clear in the e-prescription and to the patient.

Ensure that only patient directions are written in the SigText field; enter any information for the pharmacist regarding medication dispensing or counseling into the Note field.

Specify Duration of Therapy for Acute Treatments

✅ Quality Checks - Specify Duration of Therapy for Acute Treatments: Only specify duration of therapy for medications with a defined length of therapy (e.g., antibiotics).

Examples:

Appropriate: Use “amoxicillin 250 mg/5 ml suspension; take 5 mL by mouth 3 times a day for 10 days” (duration of therapy appropriately indicated for acute antibiotics treatment).

Inappropriate: “Lipitor 40 mg tablet; take 1 tablet by mouth every night for 30 days” (duration of therapy inappropriately specified for a chronic medication regimen).

Best Practices - For Technology Partners:

Ensure the system does not enter default durations of therapy for all medications in the patient directions.

Clinical Relevance/Rationale:

Most prescriptions are written for chronic medications. A duration of therapy may be appropriate for acute medications, as the defined duration may enhance a patient’s understanding of his or her therapy and increase adherence to the treatment plan. A duration of therapy listed for a chronic medication may be misinterpreted as a limit and may create a risk to patient safety if the patient believes they are intended to stop the medication at the end of the specified therapy duration.

Avoid Abbreviations, Acronyms, or Symbols

✅ Quality Checks - Avoid Abbreviations, Acronyms, or Symbols: Avoid the use of abbreviations (including Latin), acronyms and symbols when communicating patient instructions. Spell most terms out completely in English. The Institute for Safe Medication Practices (ISMP) provides a complete list of Error-Prone Abbreviations, Symbols, and Dose Designations. The abbreviations, symbols and dose designations included in this list should never be used in any part of an e-prescribing transaction.

Examples:

Use “Take one tablet by mouth twice daily” instead of “1 tablet po bid.”

Use “Instill one drop into both eyes once daily” instead of “1 gtt ou qday.”

Clinical Relevance/Rationale:

Latin abbreviations, as well as other abbreviations, are often misinterpreted. These misinterpretations can cause patients to take/use medications incorrectly, resulting in patient-safety risks.