12. TL:DR Patient Records Flashcards
9 items that need to be in ORIGINAL prescription order records
- Rx number (og)
- presciber’s name
- the full name and address of the patient
- date the origina prescription was issued and date dispensed
- name, strength, dosage form, and quantity of drug
- total number of refills authorized by prescriber
- quantity dispensed
- DEA number (if controlled), AL controlled substances number
- ID of the dispensing pharmacist
5 items that must be on the REFILL of a prescription
- name of the drug
- date of all refills
- quantity dispensed originally and on each refill
- identification of pharmacists for each refill
- total number of refills dispensed to date for that order
if a system provides a hard-copy printout of each day’s controlled substance prescription order refill data, that printout shall be verified, dated, and signed. The individual pharmacist must verify that the data indicated is correct, and then
sign this document in the same manner as he or she would sign a legal document.
in lieu of a printout of a hard copy, the pharmacy shall maintain a bound log book, or separate file, in which each individual pharmacist involved in such dispensing shall sign a statement each day attesting to the fact that the
refill info entered into the system is correct an dhas been reviewd
n addition to the controlled substances printout, a printout shall be obtained at least ___ of all new and refill prescription activity of the pharmacy for this period
at least weekly
how long should documentsation for patient records be kept
2 years
how long does a prescription file need to be kept?
not less than 2 years in which the original of every prescription compounded or dispensed shall be filed in the order fo compounding with date and number of dispensing placed on each prescription
a pharmacist and a pharmacy should respect the confidential and personal nature of professional records except
where the best interest of the patient requires or the law demands the pharmacist/pharmacy should not disclose information to anyone without proper patient authorization