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Prescribing

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Professional Standards and Guidelines Regarding Prescribing

Preamble

Prescribing medications is fundamental to good practice in medicine. Every prescription is an exercise in professional judgment, requiring appropriate judgement and clinical skills.

Renewing a prescription requires patient assessment, knowledge of the patient and medical history, effects of the medication on the patient, side effects, drug interactions and complications. Renewing a prescription is an act of prescribing giving rise to all of the expectations and requirements set out in this document.

Physicians are required to monitor the ongoing appropriateness of refill medications.

Physicians may be asked to co-sign a prescription in order to make it valid in their jurisdiction. Co-signing a prescription is an act of prescribing giving rise to all of the expectations and requirements set out in this document.

Physicians are encouraged to consider all possible barriers to the patient purchasing or taking the medications as prescribed.

This document sets out the mandatory administrative and clinical requirements for physicians when prescribing medications as well as guidelines to inform appropriate prescribing.

Professional Standards

  1. Physicians must only prescribe medications to patients within a patient-doctor relationship.

The patient-physician relationship is at the heart of the practice of medicine. The patient-physician relationship is a relationship of trust that recognizes the inherent vulnerability of the patient even as the patient is an active participant in their own care. The physician owes a duty of loyalty to protect and further the patient’s best interests and goals of care by using physician expertise, knowledge and prudent clinical judgement.

Adapted from CMA: Code of Ethics and Professionalism 2018

 

  1. Administrative
    With respect to the administrative requirements of prescribing, physicians must:
    1. comply with relevant requirements for drugs and prescribing set out in applicable legislation;
    2. ensure handwritten prescriptions are legible;
    3. ensure that there are systems in place for safe storage of medications maintained on site; and
    4. dispose of returned medications in a safe and secure manner.

Best practice is to document the disposal of returned medications, especially narcotics and controlled substances.

Prescription drug disposal

“Because most community pharmacies have procedures in place to safely dispose of patient returned medications (also called post-consumer waste), it is generally best practice for physicians to direct patients to their local pharmacy to return unused medication.

In circumstances where a physician takes possession of the patient’s drugs directly or is in possession of any other types of medications (e.g., unused or expired medication samples), physicians can contact a drug disposal company to set up their own contract for safe disposal. Physicians may further consider arranging for the disposal of unused/expired/returned drug samples directly through the pharmaceutical representative or company that has provided them.”

                                                      (source: Advice to the Profession: Prescribing Drugs, CPSO)

  1. Clinical
    With respect to the clinical requirements of prescribing:
    1. physicians must document the history, assessment, physical exam, diagnosis/differential diagnosis, and treatment plan including follow-up care in the medical record;
    2. physicians must evaluate the patient’s existing medical regime when prescribing a new This includes asking about over the counter medication and alternative or complementary medicines;
    3. when caring for patients in emergent or episodic or urgent care settings, physicians or their delegates (where the delegate is a regulated health professional) within the patient’s circle of care, must review the patient’s drug profile as maintained by the Nova Scotia Prescription Monitoring Program (NSPMP) prior to prescribing narcotics or any controlled drugs or substances;
    4. physicians must document in the patient record all prescriptions, including those ordered by telephone;
    5. physicians must discuss and document the risks and benefits of prescribed medications by providing the patient with information on the medications’ effects, interactions, adverse effects, contraindications, monitoring requirements, special precautions relevant to the prescribed medications so that informed consent can be obtained; and
    6. physicians must use extra caution when prescribing for elders regarding side effects, dosing, and polypharmacy.  All physicians are encouraged to access the most up-to-date Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

Regardless of the care setting, the College considers the information available through the Nova Scotia Prescription Monitoring Program’s (NSPMP) e-Access or the Nova Scotia Drug Information System to be part of the patient’s record. As such, physicians must be familiar with the patient information available from the NSPMP and/or the DIS.

Guidelines

  1. Prescribing in the Absence of Direct Patient Contact

Physicians should exercise caution when prescribing medications or other treatments to patients whom they have not personally examined. Before prescribing, the physicians must have knowledge of the patient’s clinical status accomplished through an assessment and diagnosis.

The College recognizes that there may be unusual circumstances where a physician may prescribe without direct in-person contact. In these circumstances the onus is on the physician to demonstrate that they could safely provide the prescription.

These circumstances include but are not limited to:

    1. An assessment may be conducted using telemedicine in accordance with the College’s Professional Standards Regarding the Provision on Telemedicine Services;
    2. Naloxone may be prescribed without face-to-face contact provided there is assurance that the recipient of the prescription will receive necessary education and training in Naloxone’s administration, in the context of a suspected opioid overdose, by an appropriate third party; an appropriate third party may include a regulated health professional or a lay person who has received the appropriate education and training to provide the service;
    3. In consultation with another physician or nurse practitioner where that other practitioner has a longitudinal relationship with the patient; and
    4. Physicians may choose to accept a previous assessment and diagnosis by a physician/nurse practitioner as a basis for further prescribing if they have reasonable grounds to believe the person has the necessary knowledge, qualifications and education and patient relationship to conduct the assessment (e.g., group practice, call group, telemedicine). The prescribing physician is accountable for how they use the assessment information and the prescribing of any medications.
  1. Electronic Prescribing (e-Prescribing)

E-Prescribing is the electronic creation and transmission of a prescription [as data] between an authorized prescriber and a patient’s pharmacy of choice, using clinical Electronic Medical Record (EMR) and pharmacy management software. e-Prescribing is designed to maintain patient confidentiality and security, decrease risk of errors and prevent prescription forgeries and diversion. (source: Canadian Medical Association and Canadian Pharmacists Association Joint Statement: ”Vision for e-Prescribing” (2012, reviewed 2019)

e-Prescriptions must:

    1. be authorized by electronic signature (or other acceptable process);
    2. require log-in and transmission by the physician;
    3. provide a secure means of prescriber authentication;
    4. prevent duplicate prescription authorization; and
    5. be accessible only by authorized recipients (pharmacies).

In Nova Scotia, pharmacies can currently access and accept only those e-prescriptions that have been created, signed and transmitted electronically within the provincial DIS – Drug Information System. (source: NS College of Pharmacists, Standards of Practice: General Pharmacy Practice, p.14 (2014))

Note: “e-Faxing” or “auto-faxing” is the creation of prescriptions within the EMR, which are then sent (as images) from the EMR to the pharmacy via fax.  These are not e-prescriptions. As with other faxed prescriptions, pharmacists must take any necessary steps to be satisfied that the identified practitioner has ordered the prescription. (source: NS College of Pharmacists, “Clarification of Current Signature for a Valid Prescription” (2019))

Electronic medical record platforms such as MedAccess and Accuro are point-to-point secure methods.

Resources

College of Physicians and Surgeons of Nova Scotia 

Canadian Medical Protective Association

Nova Scotia College of Pharmacists

The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain  

Choosing Wisely Canada

National Council on Aging

PharmacyToday.org

Document History

First approved by the Council of the College of Physicians and Surgeons of Nova Scotia on: March 26, 2021

Date of next review: 2023