Three common prescription documentation mistakes

The College of Pharmacists of British Columbia has published insights on proper prescription documentation. As part of these insights, it included three common mistakes that create non-compliance: Unclear documentation Documentation often lacks clarity, especially around which things for which registrants are taking responsibility. For example, a prescription signed with an initial with nothing beside it is ambiguous. A better option might be a stamp with the steps of a prescription laid out, so an initial might go under “preparation,” “consultation,” or “final check,” so it’s clear. However, steps can be combined together, if they’re always made by the same pharmacist, and the what’s happening is clear. Read: B.C. College of Pharmacists provides PRP support tools for hospital techs The documentation doesn’t accurately reflect the required step Misunderstandings can happen when pharmacy staff don’t know what actions need to be done for each step, the college says. That’s often an issue when it comes to verifying patient ID. Some Compliance Officers found that registrants thought that “patient identification” meant matching the name on the prescription to the label on the prescription, which is actually part of a final check. Patient identification actually means identifying the patient to make sure the right person is getting the medication. Verifying patient allergy information is another common area where mistakes are made. Compliance Officers have found some pharmacists signed to say they had verified a patient's allergy information after reviewing the information in the local or PharmaNet profile, when in fact it needs to be done directly with the patient or their representative when the prescription is filled. Read: Northern pharmacy practice: Lessons in collaboration, adaptation and reconciliation Documentation is missing for some steps Some steps are also just not documented. Some examples of this are pharmacists checking off steps instead of initialling them, counselling refusals that aren’t documented, or refills being documented less than new prescriptions are. The documentation doesn’t need to be on the prescription—it could be electronic, for example—but it has to be connected to the prescription in case it needs to be referenced later. Stamps and written policies are also examples of what’s acceptable. “The college is not prescriptive with regards to which process a pharmacy uses to document prescriptions, as long as the documentation is clear and accurately reflects registrant accountability,” the insights document says. It also reviews who can sign off on which steps. Verifying patient identification, verifying patient allergy information, preparing the prescription product, and performing the final check can be done by both pharmacists and pharmacy technicians. But reviewing PharmaNet, identifying and resolving drug therapy problems (if any), and performing patient counselling or accepting a refusal for counselling can only be done by pharmacists. Read: B.C. pharmacist who reused syringe barrel suspended for one year

Three common prescription documentation mistakes

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