Records in pharmacy

Question 1

Key elements of record-keeping in the pharmacy

Answer 1

• Confidential
• Legal
• Not kept for longer than necessary
• Legible
• Specific

Question 2

examples of diff records that are kept

Answer 2

1. Controlled Drugs (CD) register and invoices
2. Private prescription register (and record of emergency supplies)
3. Electronic Patient Medication Record (PMR)
4. Records of patient consultations
5. Records of advanced services provided to patients (e.g New Medicines Service)
6. Records of enhanced services provided to patients (e.g. under Patient Group Directions, PGDs)

Question 3

in depth example: Controlled Drugs (CD) register: Schedule 2 CD supplied would need:

Answer 3

• Date of supply
• Name & address of recipient
• Details of Prescriber or licence holder
• Quantity supplied
• Details of person collecting the schedule 2 CD
• Name & address of patient rep when applicable.
• Proof of identity was requested
• Proof of identity was provided or not

Question 4

What type of Records do we keep in a Pharmacy?

Answer 4

• clinical governance records e.g. dispensing incident reporting and audit
• records of supply e.g. controlled drug registered entry
• consultation records e.g. giving advice on weight loss to diabetics
• summary care records

Question 5

since when pharmacists had access to summary care records

Answer 5

as of 2015 - part of the national carer records service (2023)

Question 6

why keep records?

Answer 6

• invoicing
• audit trail
• research
• monitoring standard e.g. error log
• improve quality
• ensure safety
• most records are legal requirements as part of the pharmacy’s contract with the NHS.

Question 7

what to record?

Answer 7

• consultation records = relatively new to pharmacy practice: should be written so replicable with a different pharmacist
• needs 2 b concise, organised, factual, legible.
• no personal views and opinions.

Question 8

Patients have the right to request their records according to what act

Answer 8

the Data Protection Act

Question 9

what to record in a consultation

Answer 9

patient identification details e.g. name, address, d.o.b, number, identification e.g. NHS

Question 10

what are some barriers to record keeping?

Answer 10

1. time
2. knowledge - other healthcare professional such as GPs and nurses leave themselves time after a consultation to record it straight away

Question 11

example of problems involving electronically transmitted prescriptions

Answer 11

wrong drug being selected due to stemming
e.g. prescriber entering met and picking metoprolol tartrate instead of metoprolol succinate

Question 12

record summary:

• the 3 types

Answer 12

1. summary care records (SCR)
2. summary care record application (SCRa)
3. national care records service (NCRs)

Question 13

summary care records (SCR)

Answer 13

are an electronic record of important patient information, created from GP medical records. SCRs can be accessed through clinical systems or through the Summary Care Record application (SCRa).

Question 14

summary care record application (SCRa)

Answer 14

iweb-based application that allows health professionals to view clinical & demographic information. SCRa users require a smartcard, passcode and relevant role for authentication and a Health and Social Care Network (HSCN) (N3) connection.

Question 15

national care records service (NCRs)

Answer 15

new version of the Summary Care Record application (SCRa). It can be used in clinical, office or mobile environments. It does not require a smartcard and an HSCN connection, but it can still be accessed this way.

Question 16

What is the National Care Record Service?

Answer 16

• Summary of health & care information for care settings where the full patient record is not required to support their direct care. Gives access to range of clinical info.
• It includes access to more than 57.5 million Summary Care Records with patient additional information.

Question 17

what was the national care record service introduced to replace

Answer 17

National Care Records Service is the improved successor to SCRa.

Question 18

when did the NHS retire the SCRa

Answer 18

on 31 October 2023 for the majority of users.
- Web-based application can be accessed regardless of what IT system an organisation is using.

Question 19

NCRS xtra slides

Answer 19

https://www.notion.so/dispensing-and-prescriptions-1dd00bb3982d806aa330f48dd45bc7bc?pvs=4#1de00bb3982d8035870af24d92ce039b

Question 20

NCRS – gives access to SCR: what is the summary care record

Answer 20

a ‘read only’ electronic patient summary containing key clinical information.

Question 21

what info is a summary care record created with

Answer 21

with information held by who a patient’s GP practice

Question 22

when is the summary care record updated

Answer 22

whenever there is relevant change.

Question 23

As a minimum the SCR contains:

Answer 23

–Medicines: Acute, repeat and discontinued repeat items
(discontinued items will be dependent upon the GP system which
created it)
–Allergies
–Adverse reactions
–Other information may also be available on a SCR, such as
diagnoses, test results etc.

Question 24

When should the NCRS be used?

Answer 24

• Where access to a summary of key patient information is required to support clinical decision making where full detailed patient records are not required.
• to compliment local shared records by giving access to key patient information across ICS boundaries.
• where a local shared care record is not available currently
• Patient safety concerns (FGM, child protection etc)
• COVID19 vaccination status/events.

Question 25

When to use the NCRS by a pharmacist

Answer 25

- When dispensing an emergency supply (at the request of the patient) to verify the name, form, strength and dose of medicine previously had by the patient - Times when you would want to ask the GP practice for medicines/allergies/ adverse reaction information - Supporting self-care for public health services and promoting healthy lifestyles - During medicines review to verify and compare medicines currently being prescribed and their allergy status, where this is not already known - When supplying medicines under a locally commissioned service, e.g. supply of medicines on NHS Patient Group Direction (PGD), during common/minor ailments consultations

Question 26

what is the national record locator

Answer 26

- it allows health or social care workers to find and access patient information shared by other health and social care organisations across England, to support the direct care of a patient

Question 27

national record locator was established when

Answer 27

since 2018, its like an index rather than storing the actual data instead

Question 28

Common uses of NRL include:

Answer 28

- for ambulance staff - ambulance staff viewing the end of life care plan for a patient who has had an accident away from home - for care home staff - care home staff viewing the end of life plan for a patient from a previous care home - for a maternity nurse - maternity nurse viewing a mental health crisis plan for a patient giving birth in order to assess susceptibility to postnatal depression

Question 29

benefits of NRL

Answer 29

- Improve services for people with specific needs (e.g. Mental health) who present to emergency services. - Cost efficiency by avoiding duplicate care. - Support individuals’ needs / preferences (for example, - End of Life patients who request to die at home). - A better picture of local needs & demand, which can inform commissioning

Question 30

NRL benefits to Practice & Patient Safety

Answer 30

- **Pharmacy Practice:** - Reducing prescribing errors - Reducing patient harm and therefore reducing hospital admissions - Ensuring medication that is clinically appropriate is given to the patient - Better understanding of patient health - **HCP Efficiency:** - Reducing the number and duration of phone calls to the prescriber - Reducing assessment time - Being able to access required clinical information instantly - Reduces the number of faxes for communicating information - **Patient Experience:** - Reducing patients need to visit another care setting- - Supply provided sooner - Enhancing customer loyalty - Improving advice given about medication - Increasing confidence in the profession - Improving patient convenience - Supporting seven day services