Module 1: Professional Accountability and Prescribing

Lesson 4

Record keeping to increase prescription safety

The requirements for record keeping for controlled drugs and substances are outlined in the CDSA and NCPR. The regulations require a practitioner to keep a record showing the brand name of the medication or, if one does not exist, the generic name; the quantity, strength and strength per unit of the listed substance received from a licensed dealer, pharmacist, or hospital, as well as the date of receipt and the name and address of the licensed dealer, pharmacist or hospital who sold or provided the listed substance; and in the case of a listed substance sold or provided to a person, the brand name or, if one does not exist, the generic name, the quantity and strength per unit of each substance, the date on which the substance was sold or provided and the name and address of the person.

NPs must document the prescription of a controlled drug in the same manner as used for prescribing any other medication. This may require documentation of the prescribed drug in more than one place in the chart. In addition, the NP must ask the patient which pharmacy they use and note this in the patient record.

These records must be kept in a place that permits examination by an inspector at any time specified by the inspector. They must also be retained by the practitioner for a minimum of two years from the date of entry or revised entry (Canada Gazette. (2012)).