Patient medication records must be kept in the pharmacy, except in institutional pharmacies where the pharmacist has access to the necessary information in the patient's medical/clinical records.
| 2.9.1 | Patient medication records |
| (a) | Patient medication records must be developed, preferably using computer technology. |
| (b) | Patient medication records must respect the patient's privacy. |
| (c) | The following information must be captured in a patient medication record: |
| (i) | the full name of the patient; |
| (ii) | the address and telephone number of the patient; |
| (iii) | the patient's age or date of birth; |
| (iv) | the patient's gender; |
| (v) | current mass of the patient; |
| (vi) | medical aid details; |
| (vii) | the name of the prescriber and date of consultation; |
| (viii) | a list of all medicines obtained (prescription as well as non-prescription) by the patient at the point of supply during the twelve-month period immediately preceding the date of dispensing; |
| (ix) | the number allocated to each prescription dispensed and the date thereof; |
| (x) | any known allergies of the patient; |
| (xi) | any possible reactions of the patient towards medicine; |
| (xiii) | idiosyncrasies or negative reactions of the patient towards medicine; |
| (xiv) | the presence of other factors, e.g. smoking; |
| (xv) | chronic conditions or disease states of the patient; and |
| (xvi) | the identity of any other medicine or devices currently being used by the patient, and any related information indicated by a medical or other health care professional. |
| (d) | Patient medication records must: |
| (i) | be readily retrievable by manual or electronic means; |
| (ii) | enable the pharmacist to identify medicine dispensed previously and known disease conditions; and |
| (iii) | enable the pharmacist to determine the impact of medicine dispensed previously and known disease conditions upon the newly submitted prescription or other medicine sold or supplied to the patient. |
| (e) | The pharmacist must ensure a system is in place to guarantee the confidentiality of data relating to individual patients. |
| 2.9.2 | Documentation of professional activities |
Pharmacists must keep records of professional activities in a manner that allows access to information. Particular attention must be given to the following:
| (a) | The pharmacist must record all professional actions that might require confirmation in the future. |
| (b) | Up-to-date records must be kept of prescriptions as discussed above. |
| (c) | Any warning or precaution issued by professional institutions or authorised officials regarding medicines or pharmaceutical legislation must be recorded and complied with immediately. |
