APC Documentation and Record Keeping 3 — Questions and Answers
Question 1: A pharmacist receives a verbal telephone order for a Schedule 4 medicine from a known prescriber. What documentation requirement must be met?
- No documentation is needed for verbal orders
- A written record of the order must be made immediately and the written prescription obtained within the time frame set by state legislation (Correct answer)
- The verbal order can only be accepted if recorded on video
- Verbal orders for S4 medicines are never permitted under Australian law
Correct answer: A written record of the order must be made immediately and the written prescription obtained within the time frame set by state legislation
Pharmacists may act on verbal orders but must document the details immediately and obtain a written prescription within the legislated timeframe (varies by state).
Question 2: Which detail is mandatory on a hard-copy prescription for it to be legally valid in Australia?
- The patient's date of birth
- The prescriber's full name, address, and prescriber number (Correct answer)
- The patient's Medicare number
- The pharmacy's ABN
Correct answer: The prescriber's full name, address, and prescriber number
A valid prescription must include the prescriber's full name, address, and prescriber number, among other elements specified in state drug legislation.
Question 3: What does 'contemporaneous' documentation mean in a pharmacy context?
- Documentation completed by the end of the business day
- Records made at the time the event occurs, or as soon as possible afterwards (Correct answer)
- Records reviewed and approved by a supervisor once a week
- Documentation stored in a contemporary (modern) electronic system
Correct answer: Records made at the time the event occurs, or as soon as possible afterwards
Contemporaneous documentation means recording information at the time of the event to ensure accuracy and prevent retrospective falsification.
Question 4: A dispensed item is recalled by the manufacturer. Which documentation action should the pharmacist perform?
- Shred the original dispensing records to protect patient privacy
- Use dispensing records to identify and contact affected patients, and document the recall response (Correct answer)
- Wait for the Therapeutic Goods Administration (TGA) to provide a patient list
- No documentation is needed once the stock is returned
Correct answer: Use dispensing records to identify and contact affected patients, and document the recall response
Dispensing records are used to trace affected patients; the pharmacist must document all steps taken in response to the recall for accountability.
Question 5: Under the National Privacy Principles (Privacy Act 1988), how should a pharmacy store paper-based patient records?
- In an unlocked filing cabinet accessible to all staff for efficiency
- In a secure, locked area with access restricted to authorised personnel (Correct answer)
- Scanned and stored on a publicly accessible cloud drive for easy retrieval
- Disposed of after 12 months to reduce storage burden
Correct answer: In a secure, locked area with access restricted to authorised personnel
The Privacy Act requires personal health information to be stored securely with access limited to authorised staff to prevent unauthorised disclosure.
Question 6: A pharmacist annotates a prescription to record that counselling was provided. Which annotation is most appropriate?
- 'Patient happy' written in large letters across the front of the script
- Date, pharmacist initials, and a brief notation such as 'counselled' on the dispensed prescription (Correct answer)
- No annotation is needed; counselling does not require documentation
- A separate legal affidavit signed by the patient
Correct answer: Date, pharmacist initials, and a brief notation such as 'counselled' on the dispensed prescription
A date, initials, and brief note on the dispensed prescription is the standard contemporaneous record of counselling provided.
Question 7: What is the purpose of maintaining a batch record when compounding a preparation in a pharmacy?
- To record daily sales revenue from compounded products
- To document ingredients, quantities, lot numbers, compounding steps, and QC checks for traceability (Correct answer)
- To register the compounded product with the TGA as a new medicine
- To advertise the compounded product to prescribers
Correct answer: To document ingredients, quantities, lot numbers, compounding steps, and QC checks for traceability
Batch records provide a complete traceability trail for compounded preparations, supporting quality assurance and recall capability.
APC Documentation and Record Keeping 3
A pharmacist receives a verbal telephone order for a Schedule 4 medicine from a known prescriber.
What documentation requirement must be met?