Documentation Standards Flashcards
7 cards from real PEBC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation Standards flashcards as text
A pharmacist provides emergency dispensing of a medication without a valid prescription. What documentation is required?
Answer: Record the clinical rationale, quantity dispensed, attempts to contact the prescriber, and follow-up plan
Emergency dispensing requires thorough documentation of clinical justification, quantity, efforts to reach the prescriber, and follow-up to obtain a valid prescription.
Which abbreviation is considered a 'dangerous abbreviation' and should be avoided in pharmacy documentation?
Answer: U (units)
'U' for units is a dangerous abbreviation because it can be misread as '0' or '4', potentially causing a tenfold dosing error.
What is the primary reason pharmacies must document the lot number and expiry date of medications dispensed from multi-dose vials?
Answer: To enable rapid identification and recall of affected products in the event of a product recall
Lot number and expiry documentation enables pharmacies to quickly identify and contact patients who received recalled or potentially compromised products.
A patient reports an adverse drug reaction (ADR) to the pharmacy. What is the most appropriate action regarding documentation?
Answer: Document the ADR in the patient profile and report to MedEffect Canada if serious
ADRs must be documented in the patient profile, and serious ADRs should be reported to Health Canada's MedEffect program to support pharmacovigilance.
When documenting a medication substitution where a generic is dispensed instead of the brand prescribed, what must be recorded?
Answer: Both the prescribed brand name and the generic substituted, plus any required patient notification
Documentation of both the prescribed and dispensed product names, along with patient notification of the substitution, ensures transparency and accurate records.
A patient's medication profile shows a documented allergy to penicillin. A prescriber orders amoxicillin. What is the required documentation step after intervening?
Answer: Document the allergy conflict identified, communication with the prescriber, and the outcome
All clinical interventions, including allergy conflicts flagged to prescribers, must be documented with the outcome to demonstrate patient safety actions taken.
Which of the following is the correct approach to documenting a refusal of counselling by a patient?
Answer: Record that counselling was offered and declined by the patient
Documenting that counselling was offered but declined demonstrates professional due diligence and fulfills regulatory obligations.