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Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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TITLE: Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
Document Type:
CLINICAL POLICY
Keywords: ‘Enabling Policy’
Version: Published Date: Review Date:
4.0 29th December 2017 December 2020
Supersedes: Policy for pharmacist amendment of in-patient prescription charts and discharge prescriptions, v3.0, Approved Dec 2014 to Review Dec 2017
Approved by (committee/group):
Drugs and Therapeutics Committee Date Approved: 08-12-2017
Scope: (delete as applicable)
Specialty/ Department: Pharmacy
Evidence Base/ References:
Enabling Protocol for Pharmacists – Portsmouth Hospitals NHS Trust & East Hants Hospital NHS Trust
Pharmacy Enabling Protocol – United Bristol Healthcare NHS Trust
Policy and procedure for Pharmacist amendment of in-patient prescription charts and medication histories – Countess of Chester Hospital NHS Foundation Trust
Lead Division: D&O
Lead Specialty: Medicines Management (Pharmacy)
Author: Cath Fletcher, Clinical Pharmacy Services Manager
Sponsor: Medical Director
Name the documents here or record not applicable Associated Clinical Guideline(s) Not Applicable
Associated Clinical Procedure(s) Procedure for the Endorsement of In-patient Prescription Charts, Discharge and Out Patient Prescriptions
Associated Clinical Pathway(s) Not Applicable
Associated Standard Operating Procedure(s) Not Applicable
Other associated documents e.g. documentation/ forms
Not Applicable
Consultation Undertaken:
Clinical Pharmacy Team meeting 16.11.17
Template control: v1.2 August 2017 (Appendix to Clinical Documents Procedure)
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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CONTENTS
Description Page
1
Introduction / Background 2
2
Aims / Objectives / Purpose 3
3
Roles and Responsibilities 3
4
Policy Details (including flowcharts) 4-12
5
Education and Training 12
6
Definitions/ Abbreviations 12
7
Monitoring 12
8
Equality, Diversity and Inclusivity and Impact Assessments 13-14
1
Introduction / Background
Pharmacists commonly identify errors during the process of prescription chart review. To resolve these
pharmacy staff often have to interrupt doctors to request that they make appropriate changes to in-
patient and take-home prescriptions due to the fact that the Medicines Act (1968) does not authorise
pharmacists to change the prescriptions themselves unless they are registered non medical prescribers.
Pharmacists may also leave written notes requesting amendments in the medical records or with
prescriptions, but this does not guarantee that the appropriate changes will be made within a reasonable
time frame. On many occasions there is little advantage in doctors making such changes personally since
they are following the pharmacist’s recommendations. Pharmacists could have an immediate and
significant impact on this by documenting these errors in medical records and where appropriate,
amending the prescription charts directly. In some instances it would be necessary to consult the
patient’s medical team, but for others, minor amendments to medication charts are sufficient. Before
making any alteration, the pharmacist will satisfy themselves by reference to the medical notes or to the
prescriber that perceived discrepancies are not intentionally required by the medical team. If there is
any doubt as to the course of action, the patient’s medical team will be contacted before amendments to
the prescription are made.
Using pharmacists’ skills in this way may help to avoid some medication errors and reduce the number of
doses missed due to unclear or incorrect prescriptions.
Nursing staff should consider amendments to in-patient and take-home prescriptions made under this
policy to carry the same authority as prescriptions written by a doctor.
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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2
Aims / Objectives / Purpose
This policy provides guidance on what amendments a pharmacist can make to a medication chart or
discharge prescription without authorisation from the prescribing doctor. The ability to make such
clarifications on prescriptions reduces the chance of medication errors reaching the patient.
Related Trust Documents
Medicines Policy
3
Roles and Responsibilities
This policy is for use by all pharmacists employed by the Trust when providing services to Trust patients.
It will not be used by pharmacists providing services to patients of another Trust under a service level
agreement e.g. hospice patients and oncology patients. This policy is intended for use by ward
pharmacists with full access to patients’ medical notes although some minor amendments may be made
by the dispensary pharmacist. Pharmacists should be competent in medication history taking and be
familiar with the pharmaceutical and medical action plan for the patient concerned. They must have
passed their ‘professional screening’ validation and their ‘accuracy checking’ validation. Locum
pharmacists may not amend prescriptions under this policy unless authorised by the Clinical Pharmacy
Services Manager. This authorisation will be documented in the individuals personnel file.
The pharmacist will be accountable for any amendments made and these amendments should be made
in accordance with this policy. Pharmacists must always act within their level of competence. Their
primary concern must be the well-being and safety of the patient. Serious errors/omissions must be
recorded using the Trust incident reporting system (Datix).
All changes to the prescription chart made by a pharmacist should be
in green ink
written in capital letters
initialled
dated
If this cannot be achieved clearly and unambiguously on the prescription, then the whole prescription
should be re-written and signed by a doctor. It is important to consider the balance between the
pharmacist correcting prescriptions in the interest of the patient and the educational value of informing
junior doctors of their errors. To this end the pharmacist should consider whether it is necessary to
inform the appropriate doctor of any change(s) made to a prescription.
Authorisation to follow this procedure will be given by the Clinical Pharmacy Services Manager.
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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4
Policy Details (including Flowcharts)
The following tables lay out the framework for pharmacist amendment of medication charts/discharge
prescriptions and give specific guidance as to the range of actions that may be carried out in specific
situations. The pharmacist must always be satisfied that any change to a patient’s medication is not
deliberate before they make any amendments.
Pharmacists must remember that it is Trust policy to re-write prescriptions rather than amend them for
any changes in dose. Any endorsements will be made in line with the Pharmacy Department’s “Procedure
for the Endorsement of In-patient Prescription Charts, Discharge and Out Patient Prescriptions”.
The pharmacist must ensure that, where appropriate, any actions are documented and signed for in the
patient’s medical record including documenting the name of the prescriber involved in any amendments.
All amendments to a prescription chart must be signed and dated by the pharmacist making the
amendment. All amendments made on the Trust e-discharge system must be documented in the
amendments section along with the name of the prescriber consulted where appropriate.
Crossing off of any medication must be done as per Trust Medicines Policy. Medical staff must be
informed of any rewritten prescriptions which need to be signed to ensure this is done in a timely
fashion. All prescriptions written and signed by a pharmacist must have ‘Pharmacist Enabling Policy’
written after the signature.
All Pharmacists
1. Incorrect medicine/Omitted medicine
Problem Action by pharmacist Who can do this?
Item prescribed on
inpatient (IP) chart that
patient is no longer
taking
Pharmacist to clarify with medical
team that the item is not required
unless this is obvious. Once this is
done they can cross off the
prescription as per Trust
Medicines Policy, sign and date
the amendment and annotate
with the name of the prescriber
contacted. The reason for
stopping the item must be
documented in the medical notes
All ward pharmacists
Item prescribed on
discharge prescription
(TTO) that patient is no
longer taking and is not
prescribed on the IP
chart
Pharmacist to clarify with medical
team that the item is not required
unless this is obvious. On the Trust
e-discharge system the item can
be deleted from the TTO and
details recorded on the
amendments tab. The amendment
should be signed and dated with
the name of the prescriber
documented where necessary.
All pharmacists
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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Duplicated items e.g.
generic and branded
formulation prescribed
The pharmacist should check what
the patient has been taking and
cross off one prescription as per
Trust Medicines Policy, annotate
“duplicate” and sign and date the
amendment. On the Trust e-
discharge system the item can be
deleted from the TTO and details
recorded on the amendments tab
All pharmacists
Dual items prescribed
with similar therapeutic
effect but different
routes i.e. ipratropium
nebules and tiotropium
inhaler, thiamine tablets
and Pabrinex® injection
The pharmacist should clarify
which item is current therapy and
cross off the doses of the item
temporarily on hold
All pharmacists
When medication for
parenteral
administration at home
is prescribed on a TTO
and the additional
solutions for
reconstitution and
dilution are not
prescribed.
The pharmacist may supply these
items on discharge or out-patient
(OP) prescriptions as required.
The additional fluids and diluents
will be those specified in either
the medicine’s ‘Summary of
Product Characteristics’, the
University College London (UCL) IV
guide, the Trust OPAT guidelines
or the current British National
Formulary.
All additional items will be added
to the TTO record or OP
prescription
All pharmacists
Glyceryl Trinitrate spray /
tablets not on
medication chart and
patient usually on at
home.
Add to medication chart unless
contra-indication apparent from
medical notes (e.g. aortic
stenosis). Document in medical
records. Pharmacist may sign
prescription.
All ward pharmacists
Salbutamol / Terbutaline
inhalers not prescribed
on medicine chart and
patient usually on at
home.
Add to medication chart in ‘as
required’ section unless contra-
indication apparent from medical
notes. Document in medical
records. Pharmacist may sign
prescription.
All ward pharmacists
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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Patient is on
combination preparation
but only one medicine
has been prescribed e.g.
patient on Seretide but
Dr prescribed fluticasone
only
Annotate chart with details of
combination prep – if necessary
for clarity rewrite the prescription.
If there is any possibility that the
product may have been changed
check with Dr first
All ward pharmacists
2. Dose/Route/Frequency incorrect
Problem Action by pharmacist Who can do this?
Dose/formulation unclear
e.g. the dose may be
prescribed as “1 tablet” when
the medicine comes in more
than one strength
Pharmacist to clarify on the
prescription chart and initial
and date any amendment. If
the intention is unclear the
pharmacist should clarify with
the prescriber before amending
the prescription chart.
All ward pharmacists
Route of administration
incorrect (i.e. not possible)
e.g. oral specified for a
sublingual tablet, insulin
prescribed orally
Pharmacist can amend
prescription chart, initial and
date amendment
All pharmacists
Inappropriate, unclear or
ambiguous modified release
preparation prescribed
Pharmacist to amend, or
rewrite on medication chart as
appropriate. If a new
prescription is written this must
be left for the doctor to sign
All ward pharmacists
Statins prescribed in the
morning
Change to night-time dosing
(unless atorvastatin or
rosuvastatin which may be
taken at any time of the day).
Only exception is the occasional
patient who takes their statin in
the morning to assist with
compliance. Chart must be
amended as below, initialled
and dated by pharmacist
All pharmacists
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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Statin prescribed at the same
time as a macrolide
Pharmacist can cross out statin
doses during the antibiotic
course
All pharmacists
Course of medicine
completed but still prescribed
on chart or TTO
Pharmacist to stop medication
on chart and sign and date
amendment. This can be done
without consultation in the
case of medicines with fixed
course lengths e.g. naseptin
/octenisan. The prescriber
should be contacted to confirm
the course length if this can be
variable e.g. prednisolone,
antibiotics. Once clarified with
a doctor the pharmacist can
amend the prescription. In the
case of TTOs the pharmacist
can remove an item from a TTO
if the course is already
complete on the drug chart
All pharmacists
Course length missing from
TTO
If course length is clear on
inpatient prescription chart the
pharmacist can add to the TTO.
If the course length is unclear
the pharmacist must discuss
with medical team first
All pharmacists
Patient on regular compound
paracetamol preparations,
and also on when required
paracetamol preparations
Pharmacist to amend
prescriptions to avoid overdose
of paracetamol. No
documentation required in the
medical record but chart must
be annotated, initialled and
dated by pharmacist
All pharmacists
Once weekly preparations
prescribed as once daily e.g.
alendronate, methotrexate.
Also include patches applied
Pharmacist to clarify the usual
day(s) of administration and
amend the chart accordingly by
crossing through the
All pharmacists
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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every few days e.g. fentanyl,
buprenorphine, HRT
administration boxes. Add
methotrexate sticker for all
methotrexate prescriptions and
record all examples of daily
methotrexate prescriptions on
Datix incident reporting system
"When required"
prescriptions for items such
as clotrimazole cream,
aciclovir cream, nystatin
suspension. NB: These are
unlikely to be therapeutically
effective unless given
regularly.
Pharmacist to discontinue PRN
prescription and prescribe on
regular side of the medication
chart. No documentation in the
medical record is required and
the chart may be signed by a
pharmacist
All ward pharmacists
Maximum dose of “when
required” medicines not
stated
Pharmacist can add maximum
dose where appropriate
All pharmacists
3. Prescription Therapy that may result in significant patient harm
Problem Action by pharmacist Who can do this?
Prescribed therapy presents an
immediate danger to the
patient e.g. penicillin
prescribed to a patient who has
previously suffered an
anaphylactic reaction to
penicillin, or methotrexate
prescribed daily rather than
weekly
Pharmacists to liaise with
nursing staff to ensure the
medicine is not given and
discontinue it from the
medication chart. Immediate
attempts must then be made
to contact the prescriber and
the response documented in
the medical record. A Datix
incident form should also be
completed
All pharmacists
4. Missing devices and strengths
Problem Action by pharmacist Who can do this?
Inhaler strengths missing Endorse strengths
All pharmacists
Inhaler devices incorrect Endorse device, include any
additional aids used, e.g.
volumatic
All pharmacists
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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Inhaler doses missing Endorse frequency and number
of doses, e.g. 2 puffs
All pharmacists
Co-codamol prescribed with no
strength
Pharmacist to add “8/500” or
“30/500” if part of patient’s
usual medication history. If not,
discuss with Dr first.
All ward pharmacists
Insulin prescriptions lacking
information about strength,
device etc
Check medical notes first to
ensure change is not
deliberate. Pharmacist to
amend medication chart as per
medication history.
All pharmacists
Items prescribed on additional
charts but not on main
medicine chart, e.g. insulin,
warfarin, antibiotic infusions
etc.
Pharmacist can add to main
medication chart and sign
prescription. Dose should be
specified as ‘APC’
All pharmacists
5. Dosage forms
Problem Action by pharmacist Who can do this?
Patient cannot swallow
solid medication
Pharmacist to convert to
equivalent doses of liquid
preparation where possible. Any
change in preparation e.g. ferrous
sulphate tablets to ferrous
fumarate liquid requires a new
prescription to be written. If the
dose is clinically equivalent the
pharmacist can sign the
prescription
All pharmacists
Incorrect dose
prescribed on chart
when formulation
changed.
e.g. metronidazole PO
prescribed as 500mg
TDS, ciprofloxacin PO
prescribed as 400mg BD
If the item is new the pharmacist
must clarify with the doctor which
route is required. Prescription
must be rewritten but can be
signed by the pharmacist.
All pharmacists
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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6. Miscellaneous
Problem Action by pharmacist Who can do this?
Allergy information not
complete
Pharmacist to add to prescription
chart as per Trust Medicines Policy
All ward pharmacists
Multiple charts in use
but it is not specified 1
of 2, 2 of 2 etc on the
front
Pharmacist to add information to
prescription chart
All pharmacists
Post Diploma Pharmacists
1. Incorrect medicine/Omitted medicine
Transcription errors occurring
when prescription charts are re-
written or TTO is prescribed.
Pharmacist may correct obvious
discrepancies. If the intention is
unclear the pharmacist must check
with the prescriber before
amending the prescription chart or
TTO. If necessary the prescription
should be rewritten and signed by
the pharmacist
Post diploma pharmacists
Topical preparations not on
medication chart (and patient
usually uses at home) (e.g. eye/ear
drops, nasal spray, creams). Usual
regime must be confirmed with
patient before prescribing. If this is
not possible check with Dr first.
Add to medication chart unless
contra-indication apparent from
medical notes. Document in
medical records. Pharmacist may
sign prescription
.
Post diploma pharmacists
OTC (Over The Counter) medicines
that patient normally uses at
home.
These may be added to the
prescription chart when not
contra-indicated. Pharmacist may
sign prescription if verbal
agreement is obtained from
prescriber.
Post diploma pharmacists
Contraceptive Pill/ HRT not on
medication chart (and patient
usually uses at home).
Add to medication chart unless
contra-indication apparent from
medical notes (e.g. admitted with
possible DVT/PE, surgery). Check
VTE risk assessment document.
Document in medical records.
Pharmacist may sign prescription if
Post diploma pharmacists
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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verbal agreement is obtained from
prescriber. If adding in a
contraceptive pill or HRT the VTE
risk assessment should be redone
and the pharmacist must ensure
the doctor has prescribed
enoxaparin as appropriate
Non formulary oral iron
preparations and calcium/vitamin
D preparations
Convert to the nearest equivalent
dose of ferrous fumarate or Adcal
D3 unless patient has plenty of
their own supply. Pharmacist can
sign prescription
Post diploma pharmacists
2. Dose/Route/Frequency incorrect
Isosorbide mononitrate prescribed
at 08.00 and 18.00 or 08.00 and
22.00. Doses are not usually given
after 14.00 due to the need for a
nitrate free period.
Check what time the patient
usually takes their tablets at home.
Change dosing times to 08.00 and
14:00 where appropriate. Chart
must be annotated, initialled and
dated by pharmacist. Occasionally
within cardiology different dose
schedules are used for patients
with poor angina control. In such
cases contact the prescriber
before any amendment is made
Post diploma pharmacists
Diuretics prescribed 08:00 and
22:00 - night time doses are likely
to disturb sleep
Change to 08:00 and 14:00 unless
patient is catheterised or
specifically stated in medical
records or by the patient. Chart
must be annotated, initialled and
dated by pharmacist
Post diploma pharmacists
Patient has a specific routine that
they wish to adhere to and which
is agreed to be clinically
appropriate, e.g. timing of
Parkinson’s medicines
Check in medical notes to ensure
prescription has not been
deliberately changed. Dosing
schedule amended. Account must
be taken of doses already given to
ensure there is no duplication of
doses on same day. Chart must be
rewritten and signed by the
pharmacist and actions
documented in the medical
record. Pharmacist should also
discuss with nursing staff
Post diploma pharmacists
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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Medicines prescribed not in
accordance with standard
frequency of administration (e.g.
amoxicillin prescribed QDS,
clarithromycin prescribed TDS)
Pharmacist to clarify whether this
is deliberate or important e.g.
reduced doses in renal failure. If
not, pharmacist to amend dosing
frequency on medication chart and
initial and date the amendment
Post diploma pharmacists
Medicines prescribed at
inappropriate times, e.g. in
relation to meals or other
medicines, leading to potential
adverse drug reactions or
treatment failure e.g. metformin /
Creon not at mealtimes,
cholestyramine at the same time
as other medicines, iron at the
same time as ciprofloxacin,
zopiclone in the morning
Pharmacist must check with
patient what their usual routine is
especially in relation to
antidiabetic medicines. Pharmacist
can change administration times.
Account must be taken of doses
already given to ensure there is no
duplication of doses on same day.
Documentation may be required in
the medical notes depending on
the degree of alteration but the
prescription chart must be
rewritten and signed by
pharmacist.
Post diploma pharmacists
5
Education and Training
All new pharmacists will be trained and assessed on induction. Band 6 pharmacists will have their work
regularly reviewed as part of their post-graduate clinical diploma assessment process.
6
Definitions/ Abbreviations
The Trust Sherwood Forest Hospitals NHS Foundation Trust.
Staff All employees of the Trust including those managed by a third party organisation
on behalf of the Trust.
Dispensary pharmacist Pharmacist responsible for screening prescriptions in the dispensary. This
individual will have no access to the patient’s medical records
Ward Pharmacist Pharmacist responsible for providing a pharmacy service to a ward area. This
individual will have access to a patient’s medical records and can talk to patients
and medical staff face to face
Post Diploma Pharmacist Pharmacist with at least 2 years’ experience post registration who has completed
a post graduate qualification in clinical pharmacy or medicines management
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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7
Monitoring
7.0 MONITORING COMPLIANCE AND EFFECTIVENESS
Minimum Requirement
to be Monitored
(WHAT – element of compliance or effectiveness within the
document will be monitored)
Responsible Individual
(WHO – is going to monitor this element)
Process for Monitoring
e.g. Audit
(HOW – will this element be
monitored (method used))
Frequency of
Monitoring
(WHEN – will this element be monitored
(frequency/ how often))
Responsible Individual or Committee/
Group for Review of Results
(WHERE – Which individual/
committee or group will this be reported to, in what format (eg
verbal, formal report etc) and by who)
All amendments made by pharmacy staff are in line with policy requirements
Clinical Pharmacy Services Manager
Audit Annually Verbal report to Drugs & Therapeutics Committee
8
Equality, Diversity and Inclusivity and Impact Assessments
Equality Impact Assessment (EqIA) Form (please complete all sections)
Guidance on how to complete an EIA
Sample completed form
Name of service/policy/procedure being reviewed: Policy for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
New or existing service/policy/procedure: Existing
Date of Assessment:17.11.17
For the service/policy/procedure and its implementation answer the questions a – c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups’ experience? For example, are there any known health inequality or access issues to consider?
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening?
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed:
Race and Ethnicity: None NA None
Gender:
None NA None
Age:
None NA None
Religion: None NA None
Disability:
None NA None
Enabling Policy – for Pharmacist Amendment of In-patient Prescription Charts and Discharge Prescriptions
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Sexuality:
None NA None
Pregnancy and Maternity:
None NA None
Gender Reassignment: None NA None
Marriage and Civil Partnership:
None NA None
Socio-Economic Factors (i.e. living in a
poorer neighbourhood / social deprivation):
None NA None
What consultation with protected characteristic groups including patient groups have you carried out? Not needed
What data or information did you use in support of this EqIA? None
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? No
Level of impact From the information provided above and following EqIA guidance document, please indicate the perceived level of impact: Low Level of Impact For high or medium levels of impact, please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting.
Name of Responsible Person undertaking this assessment: Cath Fletcher
Signature:
Date: 17.12.17