Frequently Asked Questions
FAQ’s Regarding Record Keeping (April, 2012)
- What is a Patient Record?
A patient record is a complete reference of all documentation related to the care of a patient. It will include the patient profile, scanned copy of the original prescription, prescription information, dispensing record with pharmacist/technician signature and any documentation or information about the patient. This is consistent with patient records maintained by other health care providers. Examples of records and documents include:
• MedsCheck documentation
• Pharmacist refill authorization information
• Pharmaceutical Opinion
• Medication Management
• Identified drug related problems
• Consent forms
• Dialogue with patients or
• Any other information essential for continuity of care and
• Any future record keeping requirements under the new expanded scope of practice.
- Where are the records described in #1 to be filed and how long are they to be retained?
The content of all patient records is to be maintained in a computer system where possible and where that is not possible, in a systematic manner that allows for easy retrieval.
The entire patient record must be retained as a whole. All records and documents relating to the care of a patient, other than original written prescriptions (see #3), shall be maintained for a period of at least 10 years from the last recorded professional pharmacy service provided to the patient, or until 10 years after the day on which the patient reached, or would have reached, the age of 18 years, whichever is longer. These records and documents may be maintained as scanned originals.
- How long are prescription records to be retained?
Original prescriber generated prescriptions are to be retained for 2 years as outlined in section 156 (2) of the DRPA. However scanned electronic copies of original prescriptions will become part of the patient record which must be retained for a period of at least 10 years from the last recorded professional pharmacy service provided to the patient or until 10 years after the day on which the patient reached (or would have reached) 18 years whichever is longer. (see #2)
Note: During the transition period (see #4), where a pharmacy has not implemented technology capable of generating scanned electronic copies of every original written prescription, as well as a copy of the dispensing record (hard copy containing pharmacist/technician signature, the paper records need to be retained for a period of at least 10 years from the last recorded professional pharmacy service provided to the patient or until 10 years after the day on which the patient reached (or would have reached) 18 years whichever is longer.
- When do I have to have the scanning technology implemented?
Although the regulation established a May 11, 2012 implementation date, an extension to May 31, 2013 has been granted. By this date, all pharmacies should have implemented technology capable of generating scanned electronic copies of every original written prescription, as well as a copy of the dispensing record (hard copy containing pharmacist/technician signature).
- What types of scanners are recommended?
Please contact your software vendor for direction on scanners and how to integrate into your computer system.
- Do the records have to be retained on site?
The records must be readily retrievable and stored securely to ensure that confidentiality and privacy of the personal health information in the records is protected.
- What happens to the records when a pharmacy closes?
The College By-laws outline all requirements that must be met when closing a pharmacy, including with respect to reporting. The College must be notified of a pharmacy closing within 7 days, and within 30 days of the closing, a statement must be filed specifying where all records, including prescription files, will reside.
- What happens to the records when a pharmacy is sold?
The records of a pharmacy are considered to be part of the assets of the business and belong to the new owner in the event of a sale. This is not considered a transfer between pharmacies; therefore, all refills, part-fills and logged prescriptions remain valid.
- What is the proper method of destruction of records?
When purchasing or selling a pharmacy, members should ensure that all personal health information is dealt with appropriately whether for storage or destruction. The Office of the Information and Privacy Commissioner of Ontario has provided recommendations and guidelines to facilitate the proper destruction of personal health information. Fact Sheet #10, Secure Destruction of Personal Health Information provides a detailed guide and can be found at http://www.ipc.on.ca/images/Resources/fact-10-e.pdf .
