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PDFWAC 246-875-020

Minimum required information in an automated patient medication record system.

An automated patient medication record system is an electronic system that must have the capability of capturing any data removed on a hard copy of microfiche copy. The hard copy of the original prescription and all documents in the audit trail shall be considered a part of this system.
(1) All automated patient medication record systems must maintain the following information with regard to ambulatory patients:
(a) Patient's full name and address.
(b) A serial number assigned to each new prescription.
(c) The date of all instances of dispensing a drug.
(d) The identification of the dispenser who filled the prescription.
(e) The name, strength, dosage form and quantity of the drug dispensed.
(f) Any refill instructions by the prescriber.
(g) The prescriber's name, address, and DEA number where required.
(h) The complete directions for use of the drug. The term "as directed" is prohibited pursuant to RCW 18.64.246 and 69.41.050.
(i) Any patient allergies, idiosyncrasies, or chronic condition which may relate to drug utilization. If there is no patient allergy data the pharmacist should indicate none or "NKA" (no known allergy) on the patient medication record.
(j) Authorization for other than child-resistant containers pursuant to WAC 246-869-230, if applicable.
(2) All automated patient medication record systems must maintain the following information with regard to institutional patients:
(a) Patient's full name.
(b) Unique patient identifier.
(c) Any patient allergies, idiosyncrasies, or chronic conditions which may relate to drug utilization. If there is no patient allergy data the pharmacist should indicate none or "NKA" (no known allergy) on the patient medication record.
(d) Patient location.
(e) Patient status, for example, active, discharge, or on-pass.
(f) Prescriber's name, address, and DEA number where required.
(g) Minimum prescription data elements:
(i) Drug name, dose, route, form, directions for use, prescriber.
(ii) Start date and time when appropriate.
(iii) Stop date and time when appropriate.
(iv) Amount dispensed when appropriate.
(h) The system shall indicate any special medication status for an individual prescription, for example, on hold, discontinued, self-administration medication, investigational drugs, patient's own medications, special administration times, restrictions, controlled substances.
(i) The system shall indicate on the labeling, and in the system, (for the pharmacist, nursing and/or physician alert) any special cautionary alerts or notations deemed necessary by the dispenser for the patient safety.
[Statutory Authority: RCW 18.64.005. WSR 92-12-035 (Order 277B), § 246-875-020, filed 5/28/92, effective 6/28/92. Statutory Authority: RCW 18.64.005 and chapter 18.64A RCW. WSR 91-18-057 (Order 191B), recodified as § 246-875-020, filed 8/30/91, effective 9/30/91. Statutory Authority: RCW 18.64.005. WSR 84-03-016 (Order 181), § 360-19-030, filed 1/9/84.]
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