HOSPITAL SULTAN ABDUL AZIZ SHAH
UNIVERSITI PUTRA MALAYSIA
Document Code: HSAAS/FAR/AK85
WORK INSTRUCTION FOR OUTPATIENT PHARMACY
1.0 PURPOSE
This procedure is applicable for drug supply in outpatient medication according to the medication
order to the right patient with right medicine, right dose, right quantity and the right time of
administration.
2.0 TERMINOLOGY
DD : Dangerous Drug
HSAAS : Hospital Sultan Abdul Aziz Shah
P : Pharmacist
PA : Pharmacist Assistant
RN : Registration Number
SOP : Standard Operating Procedure
VAS : Value Added Services
3.0 GUIDE
3.1 Supply of Medication for Patient from Outpatient Clinics
No. Activity Action
1. RECEIVE PRESCRIPTION P/PA
i. Upon patient arrival, acknowledge patient’s appointment book, and manual
prescription.
ii. Check the validity of the patient's medication order. All medication orders must be
initiated by authorized prescriber and in accordance with HSAAS drug formulary
(category of prescriber, drug indication).
iii. If it is valid, generate a queue number to be given to the patient.
2. SCREENING OF PRESCRIPTION P/PA
i. Screen the completeness of prescription on the following details (whichever
applicable): -
a) Patient’s particular
b) Prescriber name, designation and MMC Number
c) Drug Category (Formulary or Non-Formulary)
d) Drug name, dose, frequency, route of administration, duration of treatment
e) Availability of the drug
f) Validity of the prescription
g) Drug interaction, polypharmacy and contraindication
h) Instruction of use
ii. Contact prescriber at respective clinic for any interventions detected.
iii. Record all interventions in the prescription and Record Form after consulting with the
relevant prescriber.
TARIKH KEMASKINI: 28/02/2024 1 drp. 5
HOSPITAL SULTAN ABDUL AZIZ SHAH
UNIVERSITI PUTRA MALAYSIA
Document Code: HSAAS/FAR/AK85
WORK INSTRUCTION FOR OUTPATIENT PHARMACY
No. Activity Action
iv. When online Putra HIS fail, transcribe any manual prescription manually into system
after online system is available.
3. ALLOCATION OF QUANTITY SUPPLIED P/PA
Verify the medication order after screening and allocate the quantity to be supplied based
on: -
i. Dose, frequency and duration
ii. Availability of the drug
iii. Patient paying status
4. LABELLING P/PA
i. Label should be printed out according to the prescription or edited when necessary.
ii. Label of the drug must contain the following: -
a) Name and strength of preparation
b) Name and RN of patient
c) Dose and frequency
d) Storage condition if any
e) Expiry and preparation date
f) Note “Controlled Medicine” and “Keep away from Children”
iii. Pass printed labels and prescription to the next filling counter for filling. Error
found on the labels must be edited and reprint.
5. FILLING P/PA
i. Fill drugs according to the prescription and label printed.
ii. Dangerous Drugs prescribed must contain details of patient’s name, identity card (IC),
quantity and date supplied. Details must be recorded in Dangerous Drug Register book
for each visit.
iii. Countercheck (CC) must be performed by other Pharmacist before proceeding to
dispensing counter.
6. COUNTERCHECK P/PA
Filled medication must be checked on the following details: -
a) Label, drug name, patient’s name, quantity, dose and instruction of use
b) Any intervention must be referred to the respective filling counter
7. CHECK PATIENT PAYING STATUS P/PA
Check for patient payment status. If patient is required to pay, refer to billing counter.
8. DISPENSE MEDICATION P/PA
i. Only trained personnel shall carry out dispensing.
ii. Filled medication must be checked on the following details: -
a) Label, drug name, patient’s name, quantity, dose and instruction of use
iii. Any intervention must be referred to the respective filling counter
iv. Call the number as stated on queue number and verify patient number, name and
identity.
TARIKH KEMASKINI: 28/02/2024 2 drp. 5
HOSPITAL SULTAN ABDUL AZIZ SHAH
UNIVERSITI PUTRA MALAYSIA
Document Code: HSAAS/FAR/AK85
WORK INSTRUCTION FOR OUTPATIENT PHARMACY
No. Activity Action
v. Dispense medication to patient with the given information e.g. drug dose, frequency,
route of administration, duration and storage.
vi. (Partial supply) Provide next collection date on patient’s prescription. Eligible patient
should be offered Value Added Services (VAS) for following visits.
vii. Patient required counselling will be referred to Pharmacist in counselling rooms.
viii. Fully supplied prescriptions will be stored and retained for record keeping. (2 years)
ix. Any uncollected medication must be kept separately and dispense based on patient
availability. (Check prescription validity)
3.2 Supply of Extemporaneous Preparation
No. Activity Action
1. SCREENING P/PA
i. Screen the prescription as in Guide 3.1.2
ii. Refer to Extemporaneous Preparation Guidelines for strength and formula of
preparation.
iii. Any preparation not in guidelines: Supply tablets and freshly prepared syrup BP;
patient required to prepare solution according to instructions provided in the label.
2. WORKSHEET PREPARATION P/PA
For listed preparation, prepare worksheet for the formulation. A complete worksheet
shall contain: -
a) Name of preparation and strength
b) Date of preparation and expiry
c) Volume of preparation
d) Worksheet ID
e) Patient name, RN and dose of the medication
f) Raw material name, batch number, manufacturer, expiry date
g) Master formula
h) Preparation Procedure
i) Sample Label
j) Name of staff prepared and counterchecked
3. LABEL PREPARATION P/PA
Label of extemporaneous shall consists of the following: -
a) Name and strength of preparation
b) Name and RN of patient
c) Dose and frequency
d) Storage condition if any
e) Expiry and preparation date
f) Note “Controlled Medicine” and “Keep away from Children”
TARIKH KEMASKINI: 28/02/2024 3 drp. 5
HOSPITAL SULTAN ABDUL AZIZ SHAH
UNIVERSITI PUTRA MALAYSIA
Document Code: HSAAS/FAR/AK85
WORK INSTRUCTION FOR OUTPATIENT PHARMACY
No. Activity Action
4. PREPARATION P/PA
i. Prepare based to the worksheet in a clean and safe workspace.
ii. Final product must be counterchecked by Pharmacist
iii. All counterchecked worksheet should be recorded and kept in Extemporaneous
Preparation File.
5. DISPENSING P/PA
Final Product is dispensed to the patient.
3.3 Supply of Discharge Medication (Outpatient)
No. Activity Action
1. MEDICATION ORDER Prescriber
Discharged medication order must be endorsed by authorized prescriber and in accordance
to HSAAS drug formulary. (Category of prescriber, drug indication)
2. SCREENING P/PA
i. Screen the medication order for the following details: -
a) Patient’s name, ward and bed number
b) Discharge summary
c) Drug name, dose, frequency, duration supply
d) Drug interaction, polypharmacy and contraindication
ii. Access to information on EMR for discharge summary. Contact prescriber for any
discrepancy between discharge summary and discharge medication order.
iii. Record any modification upon consent from prescriber as well as intervention form.
iv. Supply all DD medication based on requirements specified under Dangerous Drug Act
1952
3. ORDER VERIFICATION AND QUANTITY ALLOCATION P/PA
i. Verify the medication order and allocate quantity of medication according to the
duration given by prescriber.
ii. Allocate quantity to be supplied according to the duration prescribed.
4. LABELLING P/PA
Generate label based on patient’s medication order. Label must consist of the following
information: -
a) Name and MRN number
b) Name of drug, dose, frequency
c) Amount/quantity dispensed
d) Batch number and expiry date
e) Cautionary information
f) Dispensing date
TARIKH KEMASKINI: 28/02/2024 4 drp. 5
HOSPITAL SULTAN ABDUL AZIZ SHAH
UNIVERSITI PUTRA MALAYSIA
Document Code: HSAAS/FAR/AK85
WORK INSTRUCTION FOR OUTPATIENT PHARMACY
No. Activity Action
5. FILLING P/PA
Fill patient’s order based on discharged medication order and label accordingly.
6. COUNTERCHECKING P/PA
Countercheck medication on all patient details before dispensing.
7. DISPENSING P/PA
i. Check for patient payment status and only proceed if payment is done.
ii. Final Product is dispensed to the patient.
TARIKH KEMASKINI: 28/02/2024 5 drp. 5
