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The risk of using paperless records

February 20, 2019
Accurate record-keeping is an obligation.

Technology in the workplace can change workflow and save time. But it can also pose a risk if not used correctly.

Paperless systems used in some pharmacies mean that prescriptions no longer need to be scanned into the computer and then shredded. Now, everything can be done on the computer, from entering credentials, to doing checks electronically, to printing labels and receipts. But what happens if you get called away from the keyboard? If you are still logged on to that computer, any changes or searches that take place would still be under your profile. You are responsible for everything done under your profile, even if you are unaware.

Electronic prescriptions are acceptable, if certain conditions are met. There must be an audit trail that identifies everyone involved and their role in the process.

Some systems don’t require credentials to be entered every time you access the system, so if you walk away from the computer, someone else can use the system under your profile. If this is the case, make sure you log off every time you leave your workstation. Other systems need you to enter credentials at every step to ensure integrity.

Focus on the outcome, and make sure every transaction is reflective of who performed the transaction.  If you don’t – you are breaching the standards. Accurate record-keeping is an obligation of the licensee as stated in the Standards for the Operation of Licensed Pharmacies.

If you are the licensee, remember you have a responsibility to ensure that your pharmacy staff have the tools they need to meet their obligations to the standards.  This means having detailed policy and procedure around how data is entered, ensuring that the pharmacy software has adequate security measures, and it is able to document which pharmacy team member performs any given task. For more information, please refer to standards 8.5(b) and 8.6(d-g) in the Standards for the Operation of Licensed Pharmacies.