- The file must justify the decision, not just describe it.
- A decision not to prescribe is recorded as well.
- Each activity has its own items, such as the circumstances of a substitution.
What should be recorded for each prescription?
- Those items, clearly and concisely.
- What justifies the decision to prescribe or not.
- The interventions carried out and the follow-up to do.
- A treatment or care plan detailed enough for a colleague to take over.
What must a prescription contain?
The prescribing guide notably cites the prescriber’s identification, including permit number and contact details, the patient’s identification, information on the drug, the date written and validity period, and any other useful information. It recommends favouring a technological medium and refers to the regulation on a pharmacist’s prescriptions for the full list.
Are there items specific to certain activities?
- Substitution: notice to the patient and the circumstances of the substitution.
- Tests: results and follow-up, with enough detail for a handover.
- Administration: date, time, dose, route, site, lot number and expiry date.
- Vaccine: entry in the provincial registry within two business days.
When should information go to other professionals?
Current regulations do not require communication, but the Ordre asks pharmacists to send relevant information, especially if it affects future decisions. The guide gives several examples: a change due to an adverse effect, a new drug for a chronic disease or a treatment requiring medical follow-up. For an isolated episode, sending it may be judged less relevant. In a family medicine group or institution, recording in shared files is expected.
Can an AI tool help?
To our knowledge, the Ordre has not published a specific rule on AI. For transcription tools, Québec.ca says the professional remains responsible and must validate the generated text. See the questions to settle before adopting a tool.
Sources: OPQ, practice guide on prescribing (in French) · OPQ, practice guide on prescribing (in French) · OPQ, practice guide on prescribing (in French) · OPQ, summary of what is new (in French) · OPQ, practice guide on professional activities (in French) · OPQ, practice guide on professional activities (in French) · OPQ, practice guide on professional activities (in French) · OPQ, practice guide on professional activities (in French) · Québec.ca, AI transcription (in French) · OPQ and A.P.E.S., podcast on AI in pharmacy (in French)
General information based on the publications cited. This text does not replace professional or legal advice, or the Ordre’s guides.