PRP Insights: Documentation in Community Pharmacy
The Practice Review Program’s Pharmacy Professionals Review is grounded upon Board-approved focus areas that were identified as having the most impact on patient safety. In previous articles, we discussed the topics of patient ID verification, profile check, and counselling. The final focus area, documentation, ties everything together by leaving a written record of what has been done and identifies the registrant responsible for each step.
As part of the Pharmacy Review process, Compliance Officers review completed prescriptions to ensure all requirements are met. The results have shown us that many prescriptions are missing key additional information required at the time of dispensing, such as documentation of the registrant responsible for patient ID verification or PharmaNet check. During the Pharmacy Professionals Review, we have observed that these steps are often correctly done by the registrant, but simply failed to be documented.
The Health Professions Act (HPA) Bylaws require that at the time of dispensing, all prescriptions in community pharmacy (which includes both NEW and REFILL) must include written confirmation of the registrant who:
- verified the patient identification
- verified the patient allergy information
- reviewed the personal health information on PharmaNet*
- performed the consultation*
- performed the final check including when dispensing a balance owing
- identified and addressed a drug therapy problem, if any*
*Note that points (iii), (iv), and (vi) are clinical tasks that can only be performed and signed off by a pharmacist. The other points may be completed and signed off by any registrant (pharmacist or pharmacy technician).
Documentation is key to providing a record of accountability, and all prescriptions must have the above requirements regardless of the number of staff or workflow of the pharmacy.
Other documentation requirements within the Pharmacy Professionals Review include transmission of prescriptions to PharmaNet and keeping the PharmaNet patient record current, establishment and maintenance of patient records, documentation of emergency refills, and mandatory action to be taken when adverse drug reactions are reported by patients.
For additional information on Documentation, please refer to the full Documentation Focus Area.
This article is part of a series exploring each of the four Board-approved focus areas. To read the rest of the series, please use the following links: