Quality Management
Dispensary Activities for Community Pharmacy
Policies and Procedures
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Contents
Introduction ..................................................................................... Error! Bookmark not defined.
Opening and Closing ....................................................................................................................... 4
Pharmacy Software ......................................................................................................................... 5
Data Backups................................................................................................................................... 6
Confirming Identity ......................................................................................................................... 7
Creating and Maintaining Patient Profiles ...................................................................................... 8
Dispensing Prescriptions .................................................................. Error! Bookmark not defined.
Narcotic Prescription Dispensing ..................................................... Error! Bookmark not defined.
Emergency Fills ................................................................................ Error! Bookmark not defined.
Verbal Authorizations ...................................................................... Error! Bookmark not defined.
Electronic (facsimile) Prescriptions .................................................. Error! Bookmark not defined.
Sample Medications......................................................................... Error! Bookmark not defined.
Balance Owing ................................................................................. Error! Bookmark not defined.
Refusal to Dispense Prescriptions (Fraud) ....................................... Error! Bookmark not defined.
Refusal to Dispense Prescriptions (Other) ....................................... Error! Bookmark not defined.
Refusal to Dispense Prescriptions (Ethical) ..................................... Error! Bookmark not defined.
Prescription Reversals ...................................................................... Error! Bookmark not defined.
Schedule II and III Products .............................................................. Error! Bookmark not defined.
Prescription Label Requirements ..................................................... Error! Bookmark not defined.
Office Use Medication Dispensing ................................................... Error! Bookmark not defined.
Stock Transfers ................................................................................. Error! Bookmark not defined.
Compliance Packs ............................................................................ Error! Bookmark not defined.
Prescription Records ........................................................................ Error! Bookmark not defined.
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Introduction
The BCPhA has developed Policy and Procedure Manuals to support pharmacies in
documenting policy and procedures that ensure operational activities are compliant with the
regulatory framework governing pharmacy practice.
Each section includes open field description boxes to be completed with your practice’s
policies/procedures or checkboxes meant to act as an acknowledgement that the statement
that follows applies to your practice.
Description fields and check boxes are marked in grey so that they are easily identified.
Description fields are simple to use, just click and type into the space. Checkboxes require a
double-click followed by selecting “Checked”.
You may choose to print this booklet out upon completion to have a copy available for your
staff that need to refer to this guide while keeping the electronic copy saved when updates
need to be applied.
BCPhA has no objection if you add your organization’s logo or otherwise customize the
template. If you do so, please retain the footer crediting BCPhA.
BCPhA has made its best effort to develop this template to assist members.
The user is solely responsible for its obligations.
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Opening and Closing
Policy
The first person into the pharmacy at the time of opening must follow the opening procedures
and the last person leaving the pharmacy at time of closing must follow the closing procedures.
Purpose
To ensure that all pharmacy staff are aware of how to safely and effectively open and close the
pharmacy.
Applicability
Applies to all pharmacy staff
Implementation Procedures
Opening procedures
Please describe here or attach a list of opening duties
Closing procedure
Please describe here or attach a list of opening duties
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Pharmacy Software
Policy
The pharmacy manager must ensure that all pharmacy staff are aware of the type of computer
hardware and software and the contact information for the service providers.
Purpose
To have a known location for the information and contacts so that all pharmacy staff are able to
access and utilize the information.
Applicability
Applies to all pharmacy staff
Implementation Procedures
Computer Information
Pharmacy Software(s)
Pharmacy Software Version
Software IT support Contact(s)
Pharmacy Software(s) Training Protocol
Affiliate IT Agreements
Hardware Service Contact(s)
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Data Backups
Policy
The pharmacy manager must ensure that a procedure for ensuring that data backup occurs
consistently and in a recoverable manner.
Purpose
To make all pharmacy staff aware of the data backup procedures and who is responsible for
each days backup process.
Applicability
Applies to all pharmacy staff
Implementation Procedures
Describe the data backup procedure at your store
Identify which staff member is responsible for the procedure and who is the second if
that staff member is not available
Name of primary staff responsible
Name of secondary staff responsible
Other contacts
Repair Contact(s)
Supplies Contact(s)
Software Contact(s)
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Confirming Identity
Policy
The pharmacy manager must ensure that all pharmacy staff confirm the identity of the patient,
patient’s representative, registrant or practitioner before providing any pharmacy service
Purpose
To ensure that all pharmacy staff are aware of how to correctly confirm someone’s identity.
Applicability
Applies to all pharmacy staff
References
PODSA Bylaw 22
PPP-54 Identifying Patients for PharmaNet Processes
Implementation Procedures
All pharmacy staff must be able to recognize acceptable pieces of primary and
secondary identification for PharmaNet purposes. If patient is unknown to the
registrant, positive identification must be made by viewing 1 piece of primary or 2
pieces of secondary ID. We accept the following as valid identification.
Primary Identification
Drivers License Passport
Provincial Identity card issued by the
Province of BC
Police Identity Card issued by RCMP or
Municipality
Certificate of Indian Status Card
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Secondary Identification
Care card issued by the Province of B.C.
Birth Certificate
Canadian Citizenship Card
Landed Immigrant Status papers
Naturalization Certificate
Marriage certificate
Change of Name Certificate
Identification or Discharge Certificate from
External Affairs Canada or Canadian Armed Forces
Consular Identity Card
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Creating and Maintaining Patient Profiles
Policy
The pharmacy manager must ensure that all pharmacy staff know how to create and maintain
patient profile including the confirmation of the identity of the patient, patient’s
representative, registrant or practitioner.
Purpose
To ensure that all applicable pharmacy staff are aware of how to create and maintain the
patient’s profiles on the pharmacies computer system.
Applicability
Applies to all pharmacy staff
References
HPA Bylaw 86 Schedule F Part 1 11(1)(2)(3)
PODSA Bylaw 22
PPP-54 Identifying Patients for PharmaNet Processes
HPA Bylaw 86 Schedule F Part 1 11(1)(2)(3b)
Implementation Procedures
Creating a Patient Profile
1. If a patient is new to the pharmacy, a new patient profile must be created in the local
pharmacy software. Staff should be careful not to create duplicate profiles for the
same patient.
2. Patient identity must be confirmed prior to:
a) Establishing a patient record
b) Updating a patient’s clinical information
c) Providing a printout of an in-pharmacy or requesting a PharmaNet patient record
d) Establishing, deleting or changing a patient keyword
e) Viewing a patient record
f) Correcting information
g) Answering questions regarding the existence and content of a patient record
h) Disclosing relevant patient record information to another registrant for the
purpose of dispensing a drug or device, and/or for the purpose of monitoring drug
use
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Sign up today as a Pharmacy (Corporate) member to gain access
to the full version of this Policy & Procedures Manual and enjoy many
other Pharmacy member benefits. Please contact Linda Tinnion at 604269-2864 or by email at [email protected] to sign up or
learn more.
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