ExCPT cheat sheet

Drug class suffixes: -pril = ACE inhibitor, -sartan = angiotensin receptor blocker, -olol = beta blocker, -statin = HMG-CoA reductase inhibitor, -prazole = proton pump inhibitor, -azepam/-azolam = benzodiazepine.

Therapeutic index = TD50 ÷ ED50; a low index means a narrow safety margin and applies to warfarin, digoxin, lithium, phenytoin, and theophylline.

Steady state is reached after about 4–5 elimination half-lives; a drug is considered essentially eliminated after about 5 half-lives.

Intravenous administration gives 100% bioavailability; oral drugs undergo first-pass hepatic and gut-wall metabolism that reduces the fraction reaching systemic circulation.

CYP3A4 metabolizes roughly half of marketed drugs; grapefruit juice inhibits it, while rifampin induces it and lowers levels of CYP3A4 substrates.

Antidote pairs: opioid → naloxone; benzodiazepine → flumazenil; acetaminophen → acetylcysteine; warfarin → vitamin K (phytonadione); heparin → protamine sulfate; insulin → glucagon.

Class adverse effects: ACE inhibitors - dry cough and hyperkalemia; NSAIDs - GI ulceration and renal impairment; aminoglycosides - nephrotoxicity and ototoxicity; statins - myopathy.

An agonist binds and activates a receptor, an antagonist binds without activating, and a partial agonist produces a reduced response even at full receptor occupancy.

CSA schedules: I - no accepted medical use; II - high abuse potential, no refills; III–IV - up to 5 refills within 6 months; V - lowest abuse potential.

A Schedule II prescription given orally in an emergency must be followed by a written prescription from the prescriber within 7 days.

Controlled substance prescriptions, records, and inventories must be retained 2 years under federal law, and a biennial inventory is required.

DEA forms: 222 = ordering Schedule I/II substances; 41 = destruction of controlled substances; 106 = theft or significant loss, submitted within one business day of discovery.

The Poison Prevention Packaging Act requires child-resistant packaging for oral prescription drugs; exemptions include sublingual nitroglycerin, aerosol inhalers, and non-child-resistant packaging at the patient's request.

Orange Book ratings: A-rated products are therapeutically equivalent to the reference drug; B-rated products are not therapeutically equivalent.

HIPAA permits use or disclosure of protected health information only for treatment, payment, or operations, and only the minimum necessary amount.

Falsifying records or signatures, dispensing on an invalid order, and failing to document a known error are legal and ethical violations; errors are documented honestly under facility policy.

A valid prescription requires patient name, drug name, strength, dosage form, quantity, directions, date, and prescriber signature; controlled substances also require the prescriber's DEA number.

DEA check digit: (sum of digits 1, 3, 5) + 2 × (sum of digits 2, 4, 6); the last digit of that total must equal the seventh digit of the DEA number.

The NDC is 11 digits in 5-4-2 format (labeler-product-package); claims require the 11-digit, zero-padded version.

Sig abbreviations: qd = daily, bid = twice daily, tid = three times daily, qid = four times daily, qhs = at bedtime, prn = as needed, ac = before meals, pc = after meals.

Illegible, incomplete, or ambiguous orders must be clarified with the prescriber and the clarification documented before dispensing - the order is never guessed at.

Look-alike/sound-alike name pairs are flagged with tall man lettering (hydrOXYzine vs hydrALAZINE) during data entry and product selection.

The seven rights of dispensing: right patient, right drug, right dose, right route, right time, right reason, and right documentation.

A refill-too-soon reject occurs when a claim is submitted before roughly 75–80% of the prior fill's days supply has elapsed.

USP <795> beyond-use dates: nonaqueous preparations 180 days; water-containing oral preparations 14 days refrigerated; water-containing topical/dermal and mucosal liquids 30 days.

USP <797> assigns sterile beyond-use dates by category and storage temperature; Category 1 preparations at controlled room temperature are limited to 12 hours.

USP <800> hazardous drug handling requires a negative-pressure room (0.01–0.03 inches of water column), at least 12 air changes per hour, external venting, closed-system transfer devices, and two pairs of chemotherapy-tested gloves.

% w/v = grams of solute per 100 mL of preparation; 1% w/v = 10 mg/mL, and a 1:1000 ratio strength = 0.1% = 1 mg/mL.

Dilution formula: C1 × V1 = C2 × V2, where concentration and volume are inversely proportional.

Glass ampules require a filter needle to withdraw the contents; the filter needle is replaced with a regular needle before administration.

0.9% sodium chloride is isotonic with body fluids; the sodium chloride equivalent (E-value) method adjusts tonicity of a compounded solution.

Each compounded preparation requires a master formulation record and a compounding record listing ingredients, lot numbers, quantities, compounder identity, and assigned beyond-use date.

ISMP high-alert medications include anticoagulants, insulin, opioids, concentrated electrolytes, chemotherapy agents, and look-alike/sound-alike products.

Error-prone abbreviations to avoid: U (write units), IU, QD/QOD, trailing zeros (5.0 mg), missing leading zeros (.5 mg), MS, MSO4, and MgSO4.

Storage standards: controlled room temperature 20–25 °C (68–77 °F); refrigerator 2–8 °C (36–46 °F); freezer −25 to −10 °C.

FDA recall classes: I - reasonable probability of serious harm or death; II - temporary or reversible harm; III - unlikely to cause harm.

Root cause analysis targets system failures rather than individual blame; a just culture separates human error from at-risk and reckless behavior.

Medication reconciliation is performed at admission, transfer, and discharge to identify omissions, duplications, and interactions across care transitions.

Suspected product problems and serious adverse events are reported to FDA MedWatch; internal errors are reported through the facility's event system.

An independent double check means a second person verifies the product, calculation, and rate without seeing the first person's work.

Inventory turnover = cost of goods sold ÷ average inventory value; a higher ratio indicates faster selling and replenishment of stock.

Reorder point = (average daily use × lead time in days) + safety stock.

FEFO (first-expired, first-out) rotation means earliest-expiring stock is dispensed first; expired stock is removed, segregated, and returned through a reverse distributor.

Schedule II inventory is taken biennially, on change of the pharmacist-in-charge, and whenever requested by the DEA.

DEA Form 106 documents theft or significant loss and Form 41 documents destruction; both require supporting records and retention for at least 2 years.

On a recall, the affected lot is quarantined immediately, the quantity on hand is documented, and the manufacturer's return or destruction instructions are followed.

Controlled substances must be stored in a locked, substantially constructed cabinet or dispersed through the stock so as to obstruct the creation of a supply.

Cold-chain products are held at 2–8 °C with continuous temperature monitoring, and any excursion is documented and evaluated before the product is used.

A pharmacy benefit card supplies the 6-digit BIN, the PCN, the group number, and the cardholder ID used to route and identify an electronic claim.

A claim requires a valid 11-digit NDC, quantity, days supply, prescriber NPI, and patient identifiers; a missing or invalid field produces a reject.

Common rejects: refill too soon, prior authorization required, drug not on formulary, NDC not covered, quantity exceeds plan limit, and patient not covered.

Days supply = quantity dispensed ÷ amount the patient uses per day, based on the directions on the prescription.

DAW codes: 0 = no product selection indicated; 1 = prescriber requests brand; 2 = patient requests brand; other values are payer-specific.

Pricing benchmarks: AWP (average wholesale price), WAC (wholesale acquisition cost), NADAC (national average drug acquisition cost), and MAC (maximum allowable cost); generic claims typically pay MAC plus a dispensing fee.

A claim for a prescription that is not picked up is reversed, not deleted, and resubmitted using the original claim's identifying fields.

Medicare Part D covers outpatient prescriptions and tracks TrOOP (true out-of-pocket) spending; Medicaid is generally the payer of last resort.

Open-ended questions such as "What questions do you have about this medicine?" yield more information than yes/no questions.

Teach-back requires the patient to restate in their own words how the medication will be taken, confirming understanding.

Counseling content includes drug name and purpose, dose and directions, duration, common and serious side effects, interactions, storage, and missed-dose guidance.

HIPAA: PHI is discussed in a private counseling area and only with the patient or an authorized representative; interpreters are used for limited-English-proficiency patients.

Written patient materials should be prepared at roughly a 5th–6th grade reading level and should avoid medical jargon.

Inhaler technique: shake, exhale fully, actuate during a slow inhalation, hold breath about 10 seconds, wait 30–60 seconds between puffs, and rinse after inhaled corticosteroids.

Warfarin counseling: keep vitamin K intake consistent, complete INR monitoring, and report unusual bleeding or bruising immediately.

Insulin handling: rotate injection sites, never share pens even with a new needle, and store unopened vials at 2–8 °C.