PEBC Documentation Standards 4 — Questions and Answers
Question 1: A pharmacist provides emergency dispensing of a medication without a valid prescription. What documentation is required?
- No documentation since it is an emergency
- Record the clinical rationale, quantity dispensed, attempts to contact the prescriber, and follow-up plan (Correct answer)
- Only record the patient's name and drug dispensed
- Document that the patient signed a liability waiver
Correct 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.
Question 2: Which abbreviation is considered a 'dangerous abbreviation' and should be avoided in pharmacy documentation?
- mg (milligrams)
- BID (twice daily)
- U (units) (Correct answer)
- PO (by mouth)
Correct 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.
Question 3: What is the primary reason pharmacies must document the lot number and expiry date of medications dispensed from multi-dose vials?
- To satisfy insurance billing requirements
- To enable rapid identification and recall of affected products in the event of a product recall (Correct answer)
- To calculate storage costs per patient
- To justify higher dispensing fees
Correct 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.
Question 4: A patient reports an adverse drug reaction (ADR) to the pharmacy. What is the most appropriate action regarding documentation?
- Note it only in conversation and take no further action
- Document the ADR in the patient profile and report to MedEffect Canada if serious (Correct answer)
- Tell the patient to report it themselves without pharmacy involvement
- Discard the report if the pharmacist believes the ADR is unlikely
Correct 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.
Question 5: When documenting a medication substitution where a generic is dispensed instead of the brand prescribed, what must be recorded?
- Only the brand name as written on the prescription
- Both the prescribed brand name and the generic substituted, plus any required patient notification (Correct answer)
- The generic name only, as it is equivalent
- The substitution does not require special documentation
Correct 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.
Question 6: A patient's medication profile shows a documented allergy to penicillin. A prescriber orders amoxicillin. What is the required documentation step after intervening?
- Remove the allergy notation as it may be outdated
- Document the allergy conflict identified, communication with the prescriber, and the outcome (Correct answer)
- Dispense the medication since the prescriber ordered it and document nothing
- Only document if the prescriber insists on the order
Correct 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.
Question 7: Which of the following is the correct approach to documenting a refusal of counselling by a patient?
- No documentation is required if the patient refuses
- Record that counselling was offered and declined by the patient (Correct answer)
- Force the patient to accept counselling before dispensing
- Contact the prescriber to report the refusal
Correct 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.
PEBC Documentation Standards 4
A pharmacist provides emergency dispensing of a medication without a valid prescription.
What documentation is required?