Subject to modification by the VTH Director without approval.

Policy

The intent of this policy is to describe the process for entering prescriptions. This policy applies to all medications ordered for a VTH patient. A clinician will determine a need for a medication and whether it will be obtained from ward stock, the VTH dispensary or an outside pharmacy. The medication will be entered in the HIS (Health Information System) to document it on the patient’s medical record and then follow the next appropriate steps. 

Guidelines

All medications must be documented in the patient’s record by using a pharmacy code, ward stock charge code or Outside RX code to create a record of all medications administered and where they were obtained from.

Procedure (if applicable)

1. A clinician determines there is a need for a medication (inpatient or outpatient).
2. Someone (this could be a clinician, student or tech) enters the medication under the patient charge screen.
   • If obtaining from the dispensary, use a pharmacy charge code (purple [SAM] or blue [LAM] in most cases)
   • If obtaining using from ward stock, use the appropriate code for the service charge.
   • If sending a prescription to an outside pharmacy, use the RXOUT code and fill out the directions section to document what was prescribed, the quantity, and to which pharmacy it was sent to or if a prescription was given to a client.
3. When filled through the dispensary, the prescription ends up on the Doctor Worklist. The clinician then selects the prescription, reviews it for accuracy and enters a password to sign the prescription. We call this “pinning”.
4. Once the doctor has “pinned” the prescription, it goes on the Pharmacy worklist. A pharmacist verifies the prescription appropriateness and then enters a password to generate a label. The label prints in the dispensary and a pharmacy technician fills the prescription. 
5. A pharmacist verifies the final medication before it leaves the dispensary.
6. If the medication is a controlled substance, a duplicate label is placed on a log sheet and the person picking up the medication will date and initial next to it. These sheets are maintained for 7 years.

After Hours

• If a medication is needed from the dispensary after hours, the medication is entered as above. However, the clinician pins on both worklists and uses their I-card access to enter the dispensary and fill the non-controlled medication.
• For controlled substances, refer to the After-Hours Controls policy.

Definitions (if applicable)

HIS: (Health Information System) 

Veterinary Teaching Hospital (VTH): The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.