2. NAPRA Competencies
Proper prescription entering and checking can align with
several of the NAPRA competencies, not limited to following
the code of ethics and proper patient care. However, the main
competency this touches on falls under product distribution. As
per competency 3.1: Receive, interpret and process a
prescription, you must be able to determine the validity, clarity,
completeness and authenticity of the prescription and resolve
concerns in collaboration with the pharmacist. You must also
interpret numerals, symbols, measurement systems and Latin
abbreviations and perform pharmaceutical calculations. You
must be able to identify patterns of unusual drug prescribing
and usage including possible diversion or drug misuse and
report relevant findings to the pharmacist or appropriate
authority and process the adjudication for payment of
prescriptions and other pharmacy services using knowledge of
third-party payer policies and formularies. All these skills are
necessary for competency 3.1 and will be touched on in my
presentation.
3. Patient Information
Name, Birthdate, Address, allergy
and medical information
Physician Information
Name, CPSO, Address and clinic
information
Drug Properties
Name, Strength, and
Dosage form
Quantity, Days Supply
and Directions
What we will cover:
Patient Safety,
Packaging and Missing
Information
Billing and ONNMS
Following the Code
of Ethics
4. Patient Information
Name Address Date of Birth
Allergy Information Health Conditions
When entering and confirming a
patient it is important to ensure the
name listed is correct. Keep watch
for spelling variations and patients
that may have the same or similar
names.
Always ensure the patients
information is up to date. If the
address on the prescription does
not match the one on file, it is best
to confirm with the patient.
The correct date of birth is a must for a
patient. Using the date of birth can help
to identify if you have the correct patient.
It is also integral to the billing process to
have this information correct. Be careful
to avoid switching the month and day.
For every patient, allergy information must
be asked and included. If they have no
known drug allergies, then it must be
noted on the file. It is good practice to
update this information whenever a
patient brings in a new prescription.
Any health conditions mentioned by the
patient or prescriber should be included in the
patient's profile. All updates and changes
should also be noted.
SPECIAL NOTE- Remember that PHIPA legislation gives the patient the right
to request their personal information at any time. Always keep patient files
neat and professional.
5. Address and Clinic Information
Every prescription will have a doctors address listed; you must enter the correct address for
the physician on the file. If a physician works out of multiple locations, ensure all clinics
and location addresses are included on their file and properly denoted on the
prescription.
CPSO number
A CPSO number is assigned to all physicians at registration. This number is an identifier to help
ensure you have the correct physician. If the CPSO is missing, you may look it up on the
website https://www.cpso.on.ca/. Dentists and veterinarians have a registration number
(RCDSO and CVO) specific to their career that should also be noted.
Physician Name
When inputting physician information it is important to choose the right physician. Multiple doctors
may have the same or similar surnames so take note of spelling. It is also helpful to note what
type of physician the prescription is from to legitimize it. If the physician is a dentist, they should
not be prescribing heart medications. Be extra weary of prescriptions for controlled and narcotic
drugs from a physician that does not normally give these types of prescriptions. Always call the
physician's office and confirm any prescription that you feel may be illegitimate
Physician Information
SPECIAL NOTE: All narcotic prescriptions must include the physicians CPSO number as
well as the patients' health card number to be legitimate. You must call the physician's
office and have a new prescription faxed over if this information is missing.
6. Drug
When entering, filling and
checking a prescription the
correct drug is key. Keep a
lookout for drug name look-a-
likes as well as the
manufacturer. If the
prescription denotes “no sub”
then you must fill for the exact
drug brand listed. Otherwise,
as per the Drug
Interchangeability and
Dispensing Fee Act (DIDFA,
1990) you must dispense the
lowest costing
interchangeable. The DIN
must match and be signed off
prior to filling any
prescriptions.
Strength
Many drugs come with multiple
strengths available, make
sure to choose the
appropriate strength. Always
confirm the strength on the
prescription as patients can
have dosage changes, never
assume the strength will be
the same as the last time it
was filled. Keep an eye out
for combination drugs as they
will have two strengths
included.
Dosage Form
Drug dosage form is something
that should be determined
prior to filling a prescription. If
“O/L” is denoted ensure you
are giving an oral liquid and
not a suspension. Drugs may
also have XR, CR, and EC
(Extended release, controlled
release and enteric coated)
forms and the appropriate one
must be chosen. If a sugar-
free liquid is requested or
entered, then you MUST
dispense the sugar-free
version. These drugs often
have the same DIN for both
forms so reading the label is a
must.
Drug Properties
7. Clonidine vs.
Clonazepam
Tramadol vs.
Trazodone vs. Toradol
Hydromorphone vs.
Morphine
Celebrex vs.
Cerebyx vs.
Celexa
Hydroxyzine vs.
Hydralazine vs.
Hydrochlorothiazide
Valtrex (valacyclovir) vs.
Valcyte (valganciclovir)
Drug Soundalikes
Sertraline vs
Cetirizine
Bupropion vs
Buspirone
8. Directions
When giving medication directions it is best to stay as close to the directions the physician wrote as
possible, while still being coherent. You must always include the quantity of the dose (e.g. 1 tablet,
15mL, 2 drops etc.), the route of administration (PO, sublingually, intravenously), and the frequency
of dosing (each morning, at bedtime, every 6-8 hours). When dispensing for a child use the verb
“give” not “take”. Aways use the appropriate leading verb (see slide 9). The directions should be clear
and concise but include all necessary details.
Days Supply
Days supply must be determined by the quantity dispensed. Be careful with calculations for liquids and
always account for how many doses per day. With inhalers or drops make sure to divide the total
doses/drops by the doses per day for the days supply.
Quantity
When calculating the quantity to dispense, be sure to note the mitte on the prescription and whether the
prescription is being used for the first time. For most drug plans the standard is to dispense 100 days’
worth of a regular maintenance medication, however a smaller amount (usually 30 days) should be
dispensed the first time a drug is used. For all narcotic, targeted and controlled drugs follow proper
dispensing procedure (see next slide). When the directions give a variable dosing schedule dispense
for the lowest interval of times or the maximum doses.
Quantity, Days Supply and Directions
9. Narcotic Dispensing Rules
Narcotic medications have special dispensing rules to avoid an excess of potentially abusable
drugs from being dispensed. When a narcotic is prescribed a clear mitte must be present. There must
also be a dispensing schedule for part-fills. Repeats are NOT permitted. A potential SIG would be “1-
2 Q4-6h prnp maximum 10 per day. M:600 dispense 300 every 30 days”. The prescription should
include the strength of the drug if there are multiple strengths available. Often if the drug is given with
a variable dosage amount and interval it will include a daily maximum.
When dispensing a narcotic, you must store the dispensing record in a separate spot than the
regular prescriptions. The patient should provide ID and sign for the drug. The patient may give
permission for someone else to pick up their prescription, the person receiving the prescription must
provide ID and sign for it.
Narcotic prescriptions must also include the physicians CPSO number and the patients health
card number.
Is it best practice to keep narcotics locked in a time delayed safe until they are ready to be picked
up. Time delayed safes are a great deterrent for thieves and are in most community pharmacies now.
10. Appropriate SIG verbiage and common abbreviations
You must always write doses in mL’s not TBSP’s or TSP’s.
Ensure you use “instill” when a drop is for the eye or the ear, “Inhale” for aerosolized drugs and
“take/give” for oral medications. “Inject” is used for all intramuscular, subcutaneous or intravenous
medications, and “insert” is used for vaginal and rectal medications. “Apply” is used for topical
medications. “Spray” is for nasal spray medications.
AU- IN EACH EAR
OU- IN EACH EYE
IEN- IN EACH NOSTRIL
AS- IN LEFT EAR
AD- IN RIGHT EAR
OS- IN LEFT EYE
OD- IN RIGHT EYE
AA- AFFECTED AREAS
UD- USE AS DIRECTED
HS- AT BEDTIME
AC- BEFORE MEALS
PC- AFTER MEALS
QAM- EVERY MORNING
QPM- EVERY NIGHT
PRN- AS NEEDED
PRNP- AS NEEDED FOR PAIN
SW- SHAKE WELL
PO- BY MOUTH
SL- SUBLINGUAL
UF- UNTIL FINISHED
C- WITH
S- WITHOUT
D/C- DISCONTINUE
GTT(S)- DROP(S)
11. Missing Information
It is important to look for any missing information on a prescription. A prescription always requires
the patients name, physicians name, date and signature. Narcotic prescriptions must include
the physicians CPSO number and the patients’ Health Card number.
Packaging
All medications must be packaged with a safety cap unless the patient has requested snap caps
and signed the consent form. Appropriate auxiliary labels must be attached. Opioid warning
labels must be included with all narcotics. For puffers it is appropriate to label the puffer itself as
well as the box it comes in.
Patient Safety
Always pay special attention to any safety messages given by the pharmacy software when filling a
prescription. Highlight any bolded safety messages and bring them to the attention of the
pharmacist.
Patient Safety, Packaging and Missing Information
12. Prescription Requirements
Physicians must ensure that the following information is included on every written or electronic prescription:
-the prescribing physician’s printed name, signature (or electronic signature), and CPSO registration number;
-the prescribing physician’s practice address;
-the patient’s name;
-the name of the drug;
-the drug strength and quantity;
-the directions for use;
-the full date the prescription was issued (day, month, and year);
-refill instructions, if any;
-if the prescription is for a monitored drug, an identifying number for the patient (unless certain conditions set out
in regulation are met);
-if the prescription is for a fentanyl patch, additional requirements apply (these are set out in provision 36 and 37
of this policy); and
-any additional information required by law.
13. Billing ONNMS
Always ensure the correct
billing information is entered
for the patient. Without the
same name spelling and
birthday as the insurance
companies records the
prescription will get
declined. Patients may
need to call the insurance
company to confirm if the
information you have does
not match.
All narcotic, targeted and
controlled and controlled drugs
must be entered into the
narcotic monitoring system
(NMS). This allows the
government to keep track of
sales of narcotic drugs and
protect the public. This
reduces poly-doctoring,
multiple pharmacy usage and
abuse.
Billing and ONNMS
14. Co-Pay
The deductible is the amount you pay out-of-
pocket, on the first eligible drugs you buy,
before your coverage begins. This fee is
often paid annually, however with the
Ontario Trillium benefits, it is a quarterly
payment.
Deductible
The amount of money that a
patient with health insurance
pays for each prescription
filled. The ODB often
implements a $2 co-pay,
which some pharmacies will
waive.
Dispensing Fee
The dispensing fee payable to most
pharmacies is between $8.83 and $13.25
for each Ontario Drug Benefit (OBD)
prescription filled, except for a capitation
model for long-term care home residents,
effective January 2020. Fees depend on
location, with the standard fee at $8.83,
and higher fees up to $13.25 paid to
pharmacies in rural areas.
Prescription Cap
With a cap policy, patients are
reimbursed for their
prescription medicines up to a
maximum amount, then are
expected to pay costs higher
than this amount.
Vacation Supply
Most benefit plans allow a
vacation supply on regular
maintenance medications if a
patient is travelling out of
province. This allows you to
dispense 200 days at one time.
For opioid medications, a
prescription authorizing the
vacation supply is required
from the prescriber.
Common Billing Terms
15. Beneficence
The first foundational principle that forms and
guides our commitment to serve and protect
the best interests of our patients establishes
the fact that our primary role and function as
healthcare professionals is to benefit our
patients. We need to remember that our
patients seek our care and services because
they believe and trust that we will apply our
knowledge, skills and abilities to help make
them better.
Respect for
Persons/Justice:
The third foundational principle merges the principles
of “Respect for Persons” and “Justice” which
collectively guide our understanding of how we
ought to treat our patients. Respect for persons
acknowledges that all persons, as a result of their
intrinsic humanity, are worthy of our respect,
compassion and consideration. We demonstrate
this when we respect our patients’ vulnerability,
autonomy and right to be self-governing decision-
makers in their own healthcare. The principle of
“Justice” requires that we fulfill our ethical
obligation to treat all patients fairly and equitably.
Non maleficence
The second foundational principle that guides
our commitment to serve and protect the best
interests of our patients addresses the reality
that as we strive to benefit our patients we
must be diligent in our efforts to do no harm
and, whenever possible, prevent harm from
occurring.
Accountability
The fourth and final foundational principle directly ties
us to our professional promise to be responsible
fiduciaries of the public trust ensuring that we keep
our promise to our patients and society to always
and invariably act in their best interests and not our
own. It is this principle that holds us accountable,
not just for our own actions and behaviours, but for
those of our colleagues as well.
The Code of Ethics
16. How Does the Code of Ethics Relate to Prescription
Entering and Checking?
When you appropriately enter the patients’ information, including their medication history, medical conditions and allergy information
you are practicing non maleficence. You are preventing harm by ensuring the dispensing pharmacist knows any possible interactions.
You will display beneficence when you check every prescription thoroughly for legitimacy. Preventing counterfeit prescriptions from
being dispensed stops unprescribed drugs from being available on the street. Logging controlled and narcotic medications in the
ONNMS helps to prevent misuse as well. These actions also fall under non maleficence by preventing harmful drugs from being used
inappropriately.
Using appropriate billing techniques not only benefits the patient but is also practicing good fidelity. You should always use the
lowest costing generic available; this avoids the patient potentially paying more as well as being declined full coverage by their
benefits by getting a brand name drug. You must also have the usual and customary fee posted on signage for customers to see and
must be a reasonable fee to avoid professional misconduct. It is also fraud to misrepresent a drug claim to an insurance company.
We can practice non maleficence by dispensing naloxone kits when asked or when a patient is prescribed a considerable quantity
of narcotic medications. This can prevent someone who has consumed too much of an opioid from succumbing to an overdose as
medical help arrives. These kits can be billed to the ODB.
When we keep all information collected private and professional we show respect for persons. Every human deserves professional
medical care regardless of their background, medical and personal history.
By always keeping records of prescriptions received and medications dispensed you are showing accountability. These records
could be requested by the OCP so they must be kept organized and reasonably available.
