________________________________________Clinical Practice Pharmacy: Policy & Procedure Manual
Policy and Procedure Manual
Clinical Practice Pharmacy
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________________________________________Clinical Practice Pharmacy: Policy & Procedure Manual
GENERAL INFORMATION
A. Pharmacy Information
Pharmacy Name: ________________________________________________________________
Address: _______________________________________________________________________
Office Phone: _________________________________________
Mobile Phone: ________________________________________
After Hours Phone (if applicable): _______________________
E-mail Address: ______________________________________
Hours of Operation: __________________________________
Standard 2.8.1 All pharmacies must be open for at least twenty-five (25) hours over a minimum of four
(4) days per week unless the pharmacy manager or owner can demonstrate to Council that fewer hours
will safely meet the needs of the patients receiving care from the pharmacy.
Standard 2.1.7 Access to services shall be available during all regular hours of operation. Where “on-call”
service exists, information on how to access after-hours clinical information services shall be posted.
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
B. Staff Information
Pharmacy Manager: ____________________________________________________________________
Pharmacist(s): _________________________________________________________________________
Pharmacy Technician(s): _________________________________________________________________
Other Staff & Positions:
_____________________________________________________________________________________
_____________________________________________________________________________________
Standard 2.8.2 A licenced pharmacist does not need to be on site during all hours of operation of the
pharmacy, but the practice of pharmacy or any required supervision cannot occur without a licenced
pharmacist on site and the remaining staff must have access to the licenced pharmacist working off-site
in case of urgent situations requiring the involvement of a licenced pharmacist.
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
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________________________________________Clinical Practice Pharmacy: Policy & Procedure Manual
C. Position Descriptions
PHARMACY MANAGER:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
PHARMACIST(S):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Standard 2.1.2 All clinical information requests must be handled by a licenced pharmacist, or a
pharmacy resident (a person on the academic register) or a student or intern under the supervision
of a licenced pharmacist.
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
PHARMACY TECHNICIAN(S):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
OTHER STAFF MEMBER(S):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
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________________________________________Clinical Practice Pharmacy: Policy & Procedure Manual
SECURITY & PRIVACY
A. Pharmacy Security
Alarm Company Contact Information: _____________________________________________________
Individuals with Key(s) to Pharmacy: ______________________________________________________
Opening and Closing Procedures: _________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Standard 2.4.2 The pharmacy must be constructed in a manner of materials that protect the records
from unauthorized access.
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
B. Privacy and Security of Patient Files & Information
Storage of Patient Records: ______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Standard 2.3 Record Keeping
2.3.1 In addition to the requirements of section 79 of the regulations and in compliance with the practice
direction related to Standard of Practice #12: Records and Information, the licenced pharmacist must
retain records described in this practice direction for five (5) years.
http://mpha.in1touch.org/uploaded/web/Legislation/Records%20and%20Information.pdf
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________________________________________Clinical Practice Pharmacy: Policy & Procedure Manual
Hardware and Software Security: _________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Standard 2.4.1 Safeguards must be implemented in the receiving and sending of data to ensure patient
personal health information is kept confidential.
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
Fax Standard Compliance: _______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Standard 2.4.1 Safeguards must be implemented in the receiving and sending of data to ensure patient
personal health information is kept confidential.
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
http://mpha.in1touch.org/uploaded/web/Legislation/Records%20and%20Information.pdf
Confidentiality Agreements: _____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Mail and Deliveries: ____________________________________________________________________
_____________________________________________________________________________________
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________________________________________Clinical Practice Pharmacy: Policy & Procedure Manual
Computer Information:
Clinical Software (Software Used to Maintain Patient Information): ______________________________
_____________________________________________________________________________________
Repair Contact: ________________________________________________________________________
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________________________________________Clinical Practice Pharmacy: Policy & Procedure Manual
CLINICAL SERVICES
Patient Permission to Access Personal Health Information:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2.5.1 When accessing patient medication profile information, the clinical practice pharmacy licenced
pharmacist must document:
2.5.1.1 Written permission from the patient for access to their personal health information;
2.5.1.2 A description of the information being requested with respect to patient care;
2.5.1.3 The name of the licenced pharmacist requesting the information and reason for the request
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
Documentation of Patient Information: ________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2.2.1 Documentation of Patient Information:
Licenced pharmacists shall maintain patient profiles for all patients, and that patient profile information
shall include:
2.2.1.1 Demographic information: name, address, telephone number, date of birth (age), gender;
2.2.1.2 Clinical information such as allergies and sensitivities and, where significant, disease state and/or
chronic conditions;
2.2.1.3 A comprehensive list of medications (e.g. drug name, strength);
2.2.1.4 Use of relevant devices (e.g. self-testing, compliance devices, etc.);
2.2.1.5 Relevant prior and present medical conditions;
2.2.1.6 Non-prescription, herbal and homeopathic drug use;
2.2.1.7 Non-medicinal use of drugs, alcohol, tobacco;
2.2.1.8 Laboratory and/or physical examination results, if available.
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
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________________________________________Clinical Practice Pharmacy: Policy & Procedure Manual
Procedures for Processing Clinical Information Requests:
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Standard 2.1.4 The licenced pharmacist shall use professional expertise and judgment in processing
clinical information requests. This includes:
2.1.4.1 Obtaining the necessary background information so that the request is received in a complete
and understandable form;
2.1.4.2 Interpreting the clinical information request;
2.1.4.3 Systematically and thoroughly conducting a literature search;
2.1.4.4 Evaluating the literature in an accurate, unbiased manner;
2.1.4.5 Formulating a relevant, coherent and informative response, and
2.1.4.6 Communicating the response in a verbal and/or written form in a manner that is clear and
understandable to the recipient.
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
Procedures for Accessing Patient Health Information (ie. DPIN Profile, Laboratory Values): __________
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Procedures for Documenting Pharmacist Interventions: ______________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Standard 2.2.2 Documenting Interventions:
Licenced pharmacists shall obtain the best possible medication history of the patient, from available
sources such as the patient, DPIN profile, prescribers, other health care professionals, etc. When
providing complete clinical services, licenced pharmacists will intervene and appropriately document the
following:
2.2.2.1 Actual and potential medication related problems that are to be monitored;
2.2.2.2 Actual and potential adverse effects that are to be monitored;
2.2.2.3 Compliance;
2.2.2.4 Drug discontinuations;
2.2.2.5 Counseling on medications.
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________________________________________Clinical Practice Pharmacy: Policy & Procedure Manual
Communication with Physician(s) and/or Other Healthcare Professionals:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Standard 2.2.3 When an intervention is required, at the discretion of the licenced pharmacist, the
licenced pharmacist shall promptly forward the assessment, recommendations, and results to the most
appropriate practitioner and, if appropriate, the community licenced pharmacist, along with
recommendations to enhance patient care and quality of life. After an intervention has occurred, and the
recommendations have been made, the licenced pharmacist shall follow up with the patient within a
reasonable timeframe to ensure the recommendation has enhanced patient care.
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
Patient Counseling Procedures: __________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Standard 2.6 Patient Counseling
2.6.1 Licenced pharmacists must comply with the practice direction regarding counseling the patient
with respect to content, follow-up and privacy, as stated in the community pharmacy, as well all other
practice requirements applicable to a patient accessing the pharmacy services.
2.6.2 Content of the patient counseling information needs to be individualized for the needs of the
patient, the condition(s) being treated and the knowledge and communication level of the patient.
2.6.3 All counseling areas must:
2.6.3.1 Have acoustic and visual privacy;
2.6.3.2 Have sound panels or opaque glass, unless in a separate room;
2.6.3.3 Ensure ready access to the reference resources and patient profile;
2.6.3.4 Ensure the physical needs of the patient are met.
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________________________________________Clinical Practice Pharmacy: Policy & Procedure Manual
Reporting Adverse Events:
_____________________________________________________________________________________
_____________________________________________________________________________________
Standard 2.1.5 The licenced pharmacist shall contribute to the drug literature, by reporting any adverse
events that have impacted upon patient safety.
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
Clinical References:
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Standard 2.1.1 The pharmacy manager must ensure the pharmacy has the minimum information
resources as determined by Council
Standard 2.1.6 The licenced pharmacist shall be aware of more extensive sources of information and the
procedures necessary to access them.
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
Complaints:
Managing Complaints: __________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Incident/Discrepancy Reporting: __________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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________________________________________Clinical Practice Pharmacy: Policy & Procedure Manual
Policy and Procedure Manual:
2.7.1 Written policies and procedures for pharmacy services shall guide all personnel in the performance
of their duties.
2.7.1 A comprehensive policy and procedure manual will contain information relating to professional
responsibilities, protecting confidentiality and integrity of patient information, compliance with federal
and provincial regulations and an operational Quality Assurance Program.
2.7.3. These policies and procedures shall be updated as circumstances in the pharmacy change (e.g.
change of ownership, change of manager, etc.) or at a minimum of every three years, and dates to
indicate the time of the last review and/or revision.
http://mpha.in1touch.org/uploaded/web/Legislation/PD%20Clinical%20Practice%20&%20appendix.pdf
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