PEBC Documentation Standards 3 — Questions and Answers
Question 1: When a pharmacy technician fills a prescription, which documentation requirement applies to the supervising pharmacist?
- The pharmacist must re-enter all data entered by the technician
- The pharmacist must review and sign off to verify the final product (Correct answer)
- No additional documentation is needed if the technician is certified
- The pharmacist must contact the prescriber to confirm the order independently
Correct answer: The pharmacist must review and sign off to verify the final product
The supervising pharmacist must document their final verification of prescriptions filled by technicians, as they retain professional accountability.
Question 2: A patient is picking up a narcotic prescription. What additional documentation is typically required compared to a regular prescription?
- Only the standard prescription label
- Patient ID verification, signature, and recording in a narcotic register (Correct answer)
- A physician's countersignature at the point of pickup
- Mandatory drug counselling documentation from a nurse
Correct answer: Patient ID verification, signature, and recording in a narcotic register
Narcotics and controlled substances require enhanced documentation including patient identification, signature collection, and entries in a controlled drug register.
Question 3: Under the Controlled Drugs and Substances Act, a pharmacy discovers a discrepancy in its narcotic inventory. What is the correct documentation response?
- Adjust the register to match current stock without noting the discrepancy
- Document the discrepancy, investigate, and report to Health Canada if loss or theft is suspected (Correct answer)
- Dispose of excess inventory immediately without documentation
- Transfer the discrepancy to another pharmacy's records
Correct answer: Document the discrepancy, investigate, and report to Health Canada if loss or theft is suspected
Narcotic discrepancies must be documented, investigated, and reported to Health Canada if theft or significant loss is suspected under CDSA requirements.
Question 4: Which type of medication documentation system best supports continuity of care when a patient transitions from hospital to community pharmacy?
- Paper-based records kept only at the hospital
- A shared electronic medication record or best possible medication history (BPMH) (Correct answer)
- Verbal communication between the hospital and pharmacy staff
- Re-prescribing all medications from scratch without reference to hospital records
Correct answer: A shared electronic medication record or best possible medication history (BPMH)
A Best Possible Medication History (BPMH) or shared electronic record ensures accurate medication reconciliation during care transitions.
Question 5: What does 'chain of custody' documentation refer to in pharmacy practice?
- Records showing how a medication was transferred, handled, and stored from manufacturer to patient (Correct answer)
- The hierarchy of pharmacists supervising each other
- Documents listing pharmacy ownership over multiple years
- Certificates proving a pharmacist's license transfers between provinces
Correct answer: Records showing how a medication was transferred, handled, and stored from manufacturer to patient
Chain of custody documents the movement and handling of medications to ensure integrity, accountability, and traceability from origin to dispensing.
Question 6: A pharmacist conducts a medication review and recommends a drug therapy change. Which documentation practice is most appropriate?
- Record only the final recommendation, not the reasoning
- Document the clinical assessment, identified problem, recommendation, and follow-up plan (Correct answer)
- Notify the prescriber verbally only, with no written record
- File the recommendation under the pharmacist's personal notes, not the patient profile
Correct answer: Document the clinical assessment, identified problem, recommendation, and follow-up plan
Comprehensive documentation of clinical reasoning, recommendations, and follow-up plans supports accountability and continuity of pharmaceutical care.
Question 7: In which situation would a pharmacy be required to break patient confidentiality and disclose records without consent?
- When a curious family member asks about the patient's medications
- When required by a court order or to report a communicable disease as mandated by law (Correct answer)
- When a pharmaceutical sales representative requests patient data for market research
- When a patient's employer requests confirmation of their medication regimen
Correct answer: When required by a court order or to report a communicable disease as mandated by law
Mandatory disclosure is legally required for court orders or public health reporting of communicable diseases despite normal confidentiality obligations.
PEBC Documentation Standards 3
When a pharmacy technician fills a prescription, which documentation requirement applies to the supervising pharmacist?