Wash. Admin. Code § 246-875-030

Minimum Required Information in an Pharmacy Manual Patient Medication Record System

A manual patient medication record system consists of the hard copy original prescription and a card that contains all data on new and refill prescriptions for a patient.  This information must be organized in such a fashion that information relating to all prescription drugs used by a patient will be reviewed each time a prescription is filled.  For ambulatory patients, all manual patient medication record systems must include the following information:

•         The patient’s full name and address
•         A serial number for each new prescription
•         The date each time a drug is dispensed
•         The identification of the dispenser who filled the prescription
•         The name, strength, dosage form and quantity of the drug dispensed
•         The prescriber’s name, address and DEA number where appropriate
•         Any patient allergies or chronic conditions which may relate to drug utilization

With regards to institutional patients, all manual patient medication record systems must include the following information:

•          The patient’s full name, location and unique identifier
•         Any patient allergies or chronic conditions related to drug utilization
•         The patient’s status
•         Prescriber’s name, address and DEA number
•         Drug name, dose, route, form, directions for use and prescriber
•         Start and stop dates and times
•         If appropriate, the amount dispensed
•         Any special medication status for an individual prescription

Related Laws:  Wash. Admin. Code § 246-875-050; Wash. Admin. Code § 246-875-070