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Community Pharmacy Assessment Criteria

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Community Pharmacy Assessment Criteria. Updated August 2021
Community Pharmacy Assessment Criteria
The following chart outlines the community pharmacy operations assessment criteria that are used by Community Operations Advisors (COAs) when conducting a
community pharmacy assessment. The document is divided into categories and for each category specific standards, which have been taken from relevant
legislation, policies, guidelines or standards of practice, are identified with a link to the appropriate reference. The guidance section illustrates specific insights or
activities required to ensure adherence to the standard and is provided to assist Designated Managers and Pharmacy Staff in understanding expectations and
preparing for a pharmacy assessment.
If you have received notice of an upcoming assessment, complete this document and have it ready to share with your COA when they visit. Ensure all staff
members are aware of where the completed form is located should you not be present on the date the COA visits. For each standard, check the guidance that
your pharmacy has in place and work on achieving the remaining criteria prior to the COA visit. Educational/ Informational resources are also listed in the
Guidance Column to assist you and your pharmacy in preparing for your upcoming assessment or to ensure that your pharmacy is up to standard.
Category: General
STANDARD
GUIDANCE
The name of the Designated Manager or
certificate of registration is clear and displaye
d
in the Pharmacy.
Reference: DPRA, s.146 (3); OCP Standards of Operation for
Pharmacies
The name of the Designated Manager or certificate of registration must be clear and displayed in the
Pharmacy. The DM certificate template is available on the OCP website.
The College must be notified of a change in Designated Managers. The Acknowledgement of Change of
Designated Manager Form can be found on the OCP website.
There has been no material change to the size
or physical layout since the certificate of
accreditation was issued other than a change
that was approved by the College.
Reference: DPRA, O. Reg. 264/16, s.19; OCP Standards of
Operation for Pharmacies
The changes in the accredited area that occurred must be forwarded to the College using a Notice of
Renovation Form located on the OCP website.
All required signs are displayed as per
legislation.
Reference: DPRA, O. Reg. 264/16, s.19; OCP Standards of
Operation for Pharmacies
The Point of Care symbol in its unaltered trademarked form must be prominently and appropriately
displayed so as to be easily visible to the public either before entering the Pharmacy or immediately after
entering.
The Notice to Patient sign must be posted in an area where it can be easily seen by a person presenting a
prescription.
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Community Pharmacy Assessment Criteria. Updated August 2021
The Usual and Customary Fee sign must be posted in an area where it can be easily seen by a person
presenting a prescription.
The Point of Care symbol can be ordered by sending an email to FOS@ocpinfo.com.
The Notice to Patient and Usual and Customary Fee signs can be ordered by sending an email to
FOS@ocpinfo.com.
The College must be notified of a change in Dispensing Fee. Please send an email to
pharmacyapplications@ocpinfo.com.
Pharmacy Staff should review the Policy - Required Signage in a Pharmacy located on the OCP website.
The designated manager understands his/her
role and responsibilities with respect to the
accreditation and management of
the
pharmacy, including medication procurement
and inventory management, superv
ision of
pharmacy personnel, and
required signage.
Reference: DPRA, O. Reg 264/16, Part II; SOP for Schedule II and
III Drugs; OCP Standards of Operation for Pharmacies
The designated manager must understand his/her role and responsibilities with respect to the accreditation
and management of the pharmacy, including medication procurement and inventory management, supervision
of pharmacy personnel, and required signage.
The Designated Manager should review the College’s Designated Manager (DM) e-Learning module, which
provides an overview of the key responsibilities of a Designated Manager, in order to have a better
understanding of their responsibilities.
Category: Drug Schedules
STANDARD
GUIDANCE
Drugs will be located in an area of the
Pharmacy consistent with the appropriate drug
schedule classification and suppor
t
approval/interaction with a pharmacy
professional, as required.
Reference: DPRA, O. Reg 264/16, Part II; SOP for Schedule II
and III Drugs; OCP Standards of Operation for Pharmacies
The Pharmacist must be physically present in the Pharmacy at the time of the sale of a Schedule I, II or III
drug.
All Schedule II drugs must be sold from the dispensary, where there is no public access and no
opportunity for patient self-selection, after assessment by a Pharmacist.
The Pharmacy must develop a process to enable Pharmacists to determine the appropriateness of
Schedule II and III products for the patient in order to optimize therapeutic outcomes including a monitoring
plan.
Schedule III drugs must be available for sale in the Pharmacy from the dispensary or from an area within
10 meters of the dispensary. A Pharmacist or Intern must be available for consultation with the patient.
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Community Pharmacy Assessment Criteria. Updated August 2021
The Designated Manager shall ensure that pharmacy personnel are knowledgeable regarding the
necessity of Pharmacists to consult with patients about Schedule II products.
Over the Counter Narcotics must not be visible to the public.
Pharmacy Staff should review the Supplemental Standards of Practice for Schedule II and Schedule III
Drugs located on the OCP website.
Pharmacy Staff should review the National Drug Schedules located on the National Association of
Pharmacy Regulatory Authorities (NAPRA) website (
www.napra.ca) regularly for product scheduling.
Pharmacy Staff should review the content on the sales on non-approved marketed health products
located on the OCP website.
Pharmacy Staff should review the content on drug schedule changes located on the OCP website.
Category: Standards for Accreditation
STANDARD
GUIDANCE
The Pharmacy and dispensary is designed,
constructed and maintained to ensure the
integrity and safe and appropriate storage of all
drugs and medications and to permit optimal
work flow management.
Reference: DPRA, O. Reg 264/16, Part IV; Opening a Pharmacy
Checklist; OCP Standards of Operation for Pharmacies
The Pharmacy floor area must not be less than
18.6m² (200 ft²).
The Pharmacy must have a separate and distinct patient consultation area offering "acoustical privacy".
The Pharmacy must be constructed and maintained in a manner that protects the privacy, dignity and
confidentiality of patients and the public who receive pharmacy services.
The dispensary must be designed, constructed and maintained so that it is not accessible to the public.
The dispensary floor area must not be less than 9.3
m² (100 ft²).
The dispensary must have a minimum work surface area of 1.12m² (12ft²) for preparation, dispensing and
compounding of drugs adequate for the safe and appropriate operation of the Pharmacy.
The dispensary must have a sink with hot and cold running water adequate for the safe and appropriate
operation of the Pharmacy.
The Pharmacy must have a process in place to ensure the regular cleaning of the pharmacy, including all
premises, furniture, equipment and appliances, and automated pharmacy systems, if any.
The Pharmacy and dispensary must be maintained to ensure the integrity and the safe and appropriate storage
of all drugs and medications; including, the proper conditions of sanitation, temperature, light, humidity,
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Community Pharmacy Assessment Criteria. Updated August 2021
ventilation, segregation and security.
The Pharmacy must be designed to permit optimal work flow management, mitigate risk, support patient care
and maintain safe and effective drug distribution while providing healthcare and services to patients.
The Pharmacy has the appropriate layout,
equipment and technology to support practice.
Ref
erence: DPRA, O. Reg 264/16, s.19 & 22;
Opening a Pharmacy Checklist
; OCP Standards
of Operation for Pharmacies
; OCP Protecting
the Cold Chain Guideline
The Pharmacy must have a computer system that includes technology necessary for t
he storage and retrieval
of all documents associated with the practice of pharmacy.
The Pharmacy must have has accessible and appropriate resources available that enables practicing
members to utilize the necessary resources to make therapeutic decisions.
The Pharmacy must have access to the current required references as listed in the Req
uired Reference Guide
for Ontario Pharmacies located on the OCP website.
The Pharmacy must have
accessible and appropriate references available that enables practicing members to
utilize the necessary resources to support the delivery of patient care.
The dispensary must have equipment (i.e. balance, consumable materials such as bottles, child resistant &
light resistant vials, mortars & pestles, metric graduates, spatulas, ointment pad, etc.) necessary for the safe and
appropriate operation of the dispensary.
The dispensary must have facilities and equipment available for the appropriate cleaning of utensils and
equipment as well as a separate hand washing facility.
All cold storage equipment that store medication must be maintained at the required storage temperature
range.
Cold storage equipment must be fit for purpose and well maintained.
Temperatures must be monitored regularly. For manual recording, the minimum and maximum
temperature should be recorded twice per day.
The Designated Manager is responsible for ensuring all medications found in the refrigerator during a
temperature excursion are appropriate to dispense. The integrity of medications must be assessed and verified
such that patients do not receive a potentially sub-potent product.
Emergency preparedness processes should be in place to address any temperature excursions or breaks in
cold chain (e.g. due to equipment failure, power outages, etc.).
Standard operating policies and procedures must be in place within the pharmacy to ensure that the cold
chain is maintained throughout the time a product is received, stored, dispensed and delivered and/or
administered to the patient.
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Community Pharmacy Assessment Criteria. Updated August 2021
All pharmacy and support staff involved in handling cold chain products must be trained on cold chain
maintenance policies and procedures.
Pharmacy Staff should be familiar with the Protecting the Cold Chain Guideline and the associated
references located on the OCP website.
Pharmacy staff should review the standards specified in the Ontario Ministry of Health Vaccine Storage and
Handling Guideline.
The Pharmacy must be constructed and maintained in a manner that protects the privacy, dignity and
confidentiality of patients and the public who receive pharmacy services.
The Pharmacy must have procedures in place to ensure proper calibration and maintenance schedules are
maintained for equipment used within the dispensary.
The Designated Manager should review the Pharmacy Practice Management Systems (PPMS) Requirements
and Supplemental Requirements.
STANDARD
GUIDANCE
The Pharmacy has operational processes in
place to ensure the safe handling, storage,
and monitoring of medications to ensure
patient safety.
Reference: DPRA, O. Reg 264/16, s.19; OCP Standards of
Operation for Pharmacies
The Pharmacy must have processes in place to ensure that dispensing is done under sanitary conditions
(no direct contact with medications dispensed) and supplied to the patient safely.
The Pharmacy must have processes in place to ensure medications are stored in a safe, secure and
appropriate manner and location prior to dispensing.
The Pharmacy must have processes in place to ensure Oral Anti-Cancer Drugs (OACD) are stored and
handled by staff in a safe, secure and appropriate manner and location prior to dispensing.
The Pharmacy must have a process to safely and securely remove expired/outdated prescription
medications and chemicals (used for compounding) from the dispensing process (including automated
packaging machines) and dispose of them in a timely manner.
The Pharmacy must have a process to safely and securely remove and dispose of expired/outdated non-
prescription medications from the pharmacy.
The Pharmacy must have a process in place to ensure medications are obtained from a reputable source.
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Community Pharmacy Assessment Criteria. Updated August 2021
The Pharmacy must have a process in place for proper labelling and storage of repackaged and return to
stock medications prior to dispensing.
Pharmacy Staff should review the article Implementing the Safe Handling of Oral Anti-Cancer Drugs
(OACDs) in Community Pharmacies located on the OCP website.
The Designated Manager should review the information about the Ontario Medications Return Program
(OMRP) – a program for the responsible disposal of health products returned by the public:
http://healthsteward.ca/pharmacists/.
The Designated Manager should review the Policy - Medication Procurement and Inventory Management
located on the OCP website.
The Designated Manager should review the Standards of Operation available on the OCP website.
The Pharmacy has systems and procedures in
place to en
sure the security of controlled
substances according to national guidelines a
nd
provincial requirements.
Reference: NCR, s. 42 & 43; OCP Standards of Operation for
Pharmacies
The Pharmacist must be responsible for ensuring
that Narcotics in the Pharmacy are secure. Safeguards
include performing a narcotic reconciliation on a regular basis (at least every 6 months), with a change in
Designated Manager and after a theft or robbery.
The Pharmacist must be responsible for ensuring that Controlled Drugs in the Pharmacy are secure.
Safeguards include performing a controlled drugs reconciliation on a regular basis (at least every 6 months), with
a change in Designated Manager and after a theft or robbery.
The Pharmacist must be responsible for ensuring that Targeted Substances in the Pharmacy are secure.
Safeguards include performing a targeted substances reconciliation on a regular basis (at least every 6 months),
with a change in Designated Manager and after a theft or robbery.
The Pharmacist must take steps to identifying forgeries. Loss, theft and forgeries of Narcotics/Controlled
Drugs/Targeted Substances must be reported to Health Canada-Office of Controlled Substances in Ottawa within
10 days. Please refer to the Fact Sheet located on the OCP website.
The Pharmacy staff must follow the obligations outlined in the Safeguarding our Communities Act (Patch for
Patch Return Policy). The pharmacy staff should review the Fact Sheet - Patch-For-
Patch Fentanyl Return Program
located on the OCP website.
The Pharmacist must take steps to thoroughly investigate every discrepancy identified during a reconciliation
and to ensure that full documentation is available in a readily retrievable manner.
Discrepancies were identified during the narcotic reconciliation
Discrepancies were identified during a random review of narcotic & controlled prescriptions.
Pharmacy Staff should review the Opioid Policy located on the OCP website.
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Community Pharmacy Assessment Criteria. Updated August 2021
Pharmacy Staff should review the Guidance - Dispensing or Selling Naloxone located on the OCP Website.
Pharmacy Staff should review the Fact Sheet - Narcotic Reconciliation and Security and Video - Narcotic
Reconciliation located on the OCP website.
Pharmacy Staff should review the Fact Sheet – Forgery: Tips for Identifying Fraudulent Prescriptions and the
Fact Sheet – Forgery: Management and Reporting of Fraudulent Prescriptions.
Pharmacy Staff should review the Fact Sheet - Destruction of Narcotics, Controlled Drugs and Targeted
Substances located on the OCP website.
Pharmacy Staff should review the Fact Sheet — Narcotic Purchases on the OCP website.
Pharmacy Staff should review the content on safety and security for pharmacies located on the OCP
website.
Pharmacy Staff should review the information and resources contained in the Opioids Practice Tool located
on the OCP website.
Pharmacy Staff should review the Health Canada guidance for the handling and destruction of post-
consumer
returns containing controlled substances.
Pharmacy Staff should review the Health Canada Guidance Document for Pharmacists and Dealers Licensed
to Destroy Narcotics, Controlled Drugs or Targeted Substances: Handling and Destruction of Post-consumer
Returns Containing Narcotics, Controlled Drugs or Targeted Substances for the handling and destruction of post-
consumer returns containing controlled substances.
The Designated Manager must review the Narcotic Sales Report.
The Pharmacy should have access to the National Pain Centre's 2017 Canadian Guideline for Opioids for
Chronic Pain (
http://nationalpaincentre.mcmaster.ca/guidelines.html).
The Pharmacy has operational processes in
place to ensure when prescriptions are
delivered (or mailed), that they are both
auditable and/or traceable with a receipt for
the prescription signed by the patient or
patient's agent.
Reference: DPRA, s. 152; OCP Standards of Operation for
Pharmacies
The Pharmacy must have a process in place to
ensure all prescriptions if sent through the mail are sent only
by registered mail or, if delivered by another method, are delivered in a method that is traceable and auditable.
The Pharmacy must have a process in place to ensure confidentiality of all delivered prescriptions.
Pharmacy Staff should review the Fact Sheet - Delivery of Prescriptions located on the OCP website.
The pharmacy has implemented the AIMS,
Assurance and Improvement in Medication
The Designated Manager must ensure that all pharmacy staff have completed the required e-training
modules within the AIMS Pharmapod platform.
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Community Pharmacy Assessment Criteria. Updated August 2021
Safety program in a manner that supports
pharmacy professionals in meeting the
requirements under the supplemental
Standard of Practice.
Reference: OCP AIMS program supplemental Standard of Practice
;
OCP Standards of Operation for Pharmacies
Record: The Pharmacy must have a process in place to enable the recording on all incidents and near misses
by pharmacy staff in the platform.
The Pharmacy must have a process in place to analyze individual pharmacy incidents and near misses in a
timely manner for causal factors to reduce the likelihood of recurrence.
Share Learnings: The Pharmacy must have a process in place to enable the prompt communication of
appropriate details and actions taken of a medication incident or near miss to all pharmacy staff.
Analyze: The Pharmacy must have a process in place to utilize information (e.g. reports in the platform) to
guide the development of quality improvement initiatives.
The Pharmacy must have a process in place to implement appropriate steps to minimize the likelihood of
incident recurrence.
Document: The Pharmacy must have a process in place to document Continuous Quality Improvement (CQI)
plans and outcomes.
The Pharmacy must have a process in place to communicate Continuous Quality Improvement (CQI) plans
and outcomes with staff.
Monitor: The Pharmacy must have a process in place to monitor outcomes of Continuous Quality
Improvement (CQI) plans and improvements implemented.
The Pharmacy must have a process in place to complete the Pharmacy Safety-
Self Assessment (PSSA) (within
the first year then at least every 2-3 years).
Pharmacy Staff should review the content of the AIMS program located on the OCP website.
Pharmacy Staff should review the quarterly AIMS Response Team bulletin located on the OCP website.
Pharmacies can contact
success@pharmapodhq.com for technical support or account login difficulties with
the AIMS Pharmapod platform.
For questions about AIMS Program Standards and expectations or use/navigation
of the platform, pharmacies can contact OCP at AIMS@ocpinfo.com
The Pharmacy has a process to facilitate the
reporting of adverse reactions.
Reference:
OCP Standards of Operation for Pharmacies
The Pharmacy must develop a process to report adverse reactions involving medications, both prescription
and nonprescription, natural health products and vaccines.
The Pharmacy must develop a process that includes a framework to support Pharmacy Staff in their
obligation to report adverse reactions including prescription and non-prescription medications, natural health
products, and vaccines.
The Pharmacy should have a policy in place to address infection prevention and control (IPAC) procedures
that are in place at the pharmacy.
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Community Pharmacy Assessment Criteria. Updated August 2021
The pharmacy has operational processes in
place to ensure that infection prevention and
control practices are adhered to.
Reference:
OCP Standards of Operation for Pharmacies
The pharmacist shall review Infection Control for Regulated Healthcare Professionals: Pharmacists Edition on
the OCP website.
The pharmacy staff should be aware of Infection Prevention and Control (IPAC) resources on the Public
Health website.
The pharmacy staff should understand how and when to contact the Infection Control Professional or Public
Health.
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Community Pharmacy Assessment Criteria. Updated August 2021
Category: Standards of Practice
STANDARD
GUIDANCE
The Pharmacy has organized staffing and
workflow to enable the Pharmacist to fulfill
standards of practice and to optimize patient
care.
Reference: Model Standards of Practice for Canadian
Pharmacists 48; OCP Standards of Operation for Pharmacies
The Pharmacy must have an environment and workflow process in place, including the provision of
equipment and systems, which are necessary for the members to practice to their full scope and meet the
standards of practice of the profession.
The Pharmacy must have an environment and workflow process in place, including the provision of
appropriate staffing, that are necessary for the members to practice to their full scope and meet the standards of
the practice of the profession.
The Pharmacy must have an environment and workflow process in place, including access to resources and
training, that
are necessary for the members to practice to their full scope and meet the standards of the practice
of the profession.
The Pharmacy must have workflow processes in place to ensure accuracy in dispensing for patient safety.
The Pharmacy must have workflow processes in place to ensure prescription records are authorized at the
time of dispensing and prior to release to the patient.
The Pharmacy must have workflow processes in place to ensure dispensing records are stored in such a
manner that they are readily retrievable.
The Pharmacy must have workflow processes in place for pharmacy staff to ‘flag’ issues or opportunities to
discuss with
the patient such as: drug interactions, adherence, dosage changes, duplication of therapy, any other
drug therapy problem or counselling to improve outcomes.
The Pharmacy must develop a process for staff to gather relevant information to ensure patient files are
complete and comprehensive including information such as indication, allergies, medical conditions, prescr
iption
history, use of over the counter/natural health products and changes to health status.
The Pharmacy must develop a process for staff to gather relevant information for new prescriptions to
ensure patient files are complete and comprehensive including information such as indication, allergies, medical
conditions, prescription history, use of over the counter/natural health products and changes to health status.
The Pharmacy must develop a process for staff to gather relevant information on refill prescriptions to ensure
patient files are complete and comprehensive including information such as changes to allergies, medical
conditions, prescription history, use of over the counter/natural health products, changes to health status and
indication.
The P
harmacy must have a workflow process in place to ensure that opportunities for pharmacists to perform
patient assessment, decision-making and communication are not bypassed. There must be a process in place,
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Community Pharmacy Assessment Criteria. Updated August 2021
and adhered to, that ensures that the Pharmacist is alerted to these opportunities.
The Pharmacy must have a process in place to ensure all pharmacy staff members and trainees are provided
with the appropriate level of supervision and/or delegation on a regular & ongoing basis.
The Pharmacy must have processes and procedures in place to support the safe and appropriate assessment
and delivery of vaccines.
The Pharmacy must have operational policies and procedures in place that ensures that pharmacy
professionals comply with their professional and legal obligations and are empowered to exercise professional
judgement to optimize patient care.
The Pharmacy must develop a process to ensure a therapeutic check is conducted for patients receiving refill
prescriptions, both on a regular basis and each time there is a change to the patient’s medication regimen or
health status to ensure ongoing appropriateness of therapy.
The Pharmacy must have processes and procedures in place to support transitions of care between hospital
and community settings including proper medication reconciliation.
The Pharmacy must develop a process to ensure a therapeutic check is conducted for patients using multi-
medication compliance aids, both on a regular basis and each time there is a change to the patient’s medication
regimen or health status to ensure ongoing appropriateness of therapy. This includes PRN medications.
Pharmacy Staff should review the Model Standards of Practice for Pharmacists located on the OCP website.
Pharmacy Staff should review the Fact Sheet - Supervision of Pharmacy Students & Interns located on the
OCP website.
Pharmacy Staff should review the Code of Ethics located on the OCP website.
The Designated Manager should review the Policy - Professional Supervision of Pharmacy Personnel located
on the OCP website.
The Designated Manager should review the Policy - Centralized Prescription Processing (Central Fill) located
on the OCP website.
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Community Pharmacy Assessment Criteria. Updated August 2021
The Pharmacy has integrated Pharmacy
Technicians to fulfill standards of practice and
to optimize patient care.
Reference: Model Standards of Practice for Pharmacy
Technicians; OCP Standards of Operation for Pharmacies
Pharmacy Technicians must not perform the task of
ensuring the pharmaceutical and therapeutic suitability
of a drug for its intended use.
The Pharmacy must develop a process for the Pharmacy Technician to ensure a therapeutic check by a
Pharmacist has occurred before a new prescription is released to the patient.
The Pharmacy must develop a process for the Pharmacy Technician to ensure a therapeutic check by a
Pharmacist has occurred before a refill prescription is released to the patient.
Pharmacy Staff should review the information on the Pharmacy Technicians Practice Tools page located on
the OCP website.
Pharmacy Staff should review the Model Standards of Practice for Pharmacy Technicians located on the OCP
website.
Pharmacy Staff should review the content on integrating Pharmacy Technicians into community practice
located on the OCP website.
Prescriptions received and documentation of
services provided by the Pharmacy are
complete, authentic and meet all legal and
professional requirements.
Reference: Model Standards of Practice for Canadian
Pharmacists 1.36 - 1.42; OCP Standards of Operation for
Pharmacies
The Pharmacy must ensure prescriptions originate from the prescriber and authenticity is established.
The Pharmacy must ensure that verbal prescriptions and authorizations include the date received, the
name of member who received the verbal direction and the amount (including refills) prescribed.
The Pharmacy must ensure prescription transfers meet all the requirements listed in the Drug and
Pharmacies Regulation Act (DPRA).
Pharmacy Staff should review the Policy – Faxed Transmission of Prescriptions located on the OCP website.
Pharmacy Staff should review the Policy - Medical Directives and the Delegation of Controlled Acts located
on the OCP website.
Pharmacy Staff should review the Policy - Treating Self and Family Members located on the OCP website.
Pharmacy Staff should review the Guideline - Preventing Sexual Abuse and Harassment located on the OCP
website.
Pharmacy Staff should review the Position Statement - Authenticity of Prescriptions using Unique Identifiers
for Prescribers located on the OCP website.
Pharmacy Staff should review the Fact Sheet - Prescription Transfers located on the OCP website.
Pharmacy Staff should review the Prescription Regulation Summary Chart (Summary of Laws) located on the
OCP website
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Community Pharmacy Assessment Criteria. Updated August 2021
Prescriptions that are dispensed are
accurately
prepared, packaged and labelled
according to legal and professional
requirements.
Reference: Model Standards of Practice for Canadian
Pharmacists 1.37 - 1.42; OCP Standards of Operation for
Pharmacies
The Pharmacy must ensure that all prescriptions
are labelled as outlined in the Drug and Pharmacies
Regulation Act (DPRA) including the trading name, ownership name, address and telephone number of the
Pharmacy.
The Pharmacy must ensure that multi-compliance aids are labelled as per OCP Guideline including the
information that would appear if each drug had been dispensed in individual vials, in addition to the description
of the shape and colour of the tablet or capsule in a manner that meets the needs of the patient.
Pharmacy Staff should review the Guideline - Multi Medication Compliance Aids located on the OCP website.
The Designated Manager should review the Policy - Labelling Single Entity Drugs located on the OCP
website.
Effective documentation and recordkeeping
procedures are in place
that protect patient
confidentiality.
Reference: DPRA, O. Reg. 264/16, s. 19, 20 & 21;
OCP Standards
of Operation for Pharmacies
The Pharmacy must ensure that personal health information of patients is protected as pharmacy services
are received by patients.
The Pharmacy must ensure that when disposing of confidential information that it be performed in a
manner that ensures confidentiality.
The Pharmacy must either maintain records in a paper OR an electronic format OR it is moving towards a
complete electronic record. All patient records, regardless of form must be readily retrievable and maintained
appropriately for a time period not less than 10 years from the last professional pharmacy service. More
information can be found on the OCP website.
The Pharmacy must develop a process to retrieve pertinent information regarding red flag scenarios/drug
therapy problems such as drug interactions, precautions and contraindications that have been managed
(through discussion with the patient and/or prescriber) for future patient assessment.
The Pharmacy must have a process in place to document pertinent information in the patient record (i.e.,
gathered information, issues identified, decisions made, rationale and further follow up/monitoring plan) in a
way that is timely, readily retrievable, saved in a standardized fashion (like in a “patient chart”) and done
consistently to ensure continuity of care and that patient outcomes are optimized.
The Pharmacy must develop a process to ensure that relevant information obtained during a medication
review (i.e., use of other medications, over the counter products, natural health products, changes to health
status and allergies) is entered into the patient record for future patient assessments.
The Pharmacy must develop a process to ensure that relevant information obtained while delivering a
service, which include important clinical documentation to support continuity of care, is entered into the
patient record for future patient assessments.
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Community Pharmacy Assessment Criteria. Updated August 2021
Pharmacy Staff should review the Guideline - Record Retention, Disclosure and Disposal located on the OCP
website.
Pharmacy Staff should review the Fact Sheet - Record Keeping and Scanning Requirements located on the
OCP website.
Pharmacy Staff should review the Fact Sheet - Releasing Personal Health Information located on the OCP
website.
Pharmacy Staff should review the Information and Privacy Commissioner of Ontario's resource - Circle of
Care: Sharing Personal Health Information for Health-Care Purposes located on the OCP website.
The Pharmacy has processes in place to ensure
that services provided are done so with
appropriate equipment and facilities that
protect patient’s privacy while optimizing
therapeutic outcomes.
Reference: OCP Standards of Operation for Pharmacies
The Pharmacy must have appropriate equipment and facilities that protects the privacy and dignity of
the patients and the public who receive pharmacy services (i.e. vaccination services).
The Pharmacy must ensure that there is a process in place that ensures all services are appropriate and
safely delivered based on a review and assessment of patients’ circumstances and provided in order to
optimize therapeutic outcomes. (i.e. vaccination services, point of care services).
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Community Pharmacy Assessment Criteria. Updated August 2021
STANDARD
GUIDANCE
The Pharmacy has operational standards in
place to ensure the Lock and Leave area
completely restricts public access to all
scheduled drugs.
Reference: DPRA O. Reg 264/16, s.23
The Pharmacy must ensure that all Schedule III
products are located inside the Lock and Leave area or in a
locked section that is not accessible to the public in the absence of the Pharmacist.
Category: Long Term Care
STANDARD
GUIDANCE
The Pharmacy has policies and procedures in
place to address facility specific agreements.
Reference: Standards for Pharmacists Providing Services to
Licensed Long-Term Care Facilities
The Pharmacy must have policies and procedures
in place to address facility specific agreements.
Pharmacy Staff should review the Standards for Pharmacists Providing Services to Licensed Long-Term Care
Facilities located on the OCP website.
Category: Delegation
STANDARD
GUIDANCE
There is a delegation process in place
authorizing an individual to perform a
controlled act in the Pharmacy.
Reference: RHPA S.O. 1991, c18 s. 27 (1) (a,b), FHRCO
Pharmacy Act 1991, O. Reg 202/94, s.12 (5).
The Designated Manager must ensure a delegation process is in place for all Controlled Acts undertaken by
regulated and unregulated staff in the pharmacy who are not authorized to perform these Acts.
The Designated Manager should review the OCP policy on Medical Directives and the Delegation of
Controlled Acts.
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Completed 6 January 2022

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