Pharmacist Prescribing: Initiating, Adapting and Renewing Prescriptions

Purpose:

This guideline outlines legislative requirements and expectations for pharmacists prescribing a drug as authorized by the Pharmacy Act  and O. Reg. 202/94. It is meant to be used alongside the  Standards of PracticeStandards of Operation, and Code of Ethics.

Definitions:

Pharmacy professional: Pharmacy professional refers to a pharmacist and/or a pharmacy technician. For the purposes of this guideline, where the term ‘pharmacist’ is used, it means a pharmacist in Part A of the register and is inclusive of pharmacy interns and students, and subject to any terms, conditions and limitations on their certificates of registration. Where this is not the case, it will be clearly identified.

Minor Ailment: Health conditions that can be managed with minimal treatment and/or self-care strategies. Additional criteria include: usually a short-term condition; lab tests are not usually required; low risk of treatment masking underlying conditions; medications and medical histories can reliably differentiate more serious conditions; and, only minimal or short-term follow up is required. Minor ailments approved for pharmacist prescribing are listed in Schedule 4 of O. Reg. 202/94.

Guideline:

Pharmacists have the authority to initiate, adapt or renew a prescription in accordance with the regulations if:

  • They possess sufficient knowledge and skills respecting the drug and the patient’s condition to do so safely and effectively.
  • It is in the best interest of the patient and appropriate, given the known risks and benefits of prescribing the drug.

Initiating a Prescription[1]

Pharmacists are authorized to prescribe the following:

  • Varenicline tartrate and/or bupropion hydrochloride for smoking cessation.
  • A drug listed in Column 3 of Schedule 4 to O. Reg. 202/94 for the associated minor ailment in Column 1.
    • Publicly funded minor ailment services must be provided in accordance with Ministry of Health requirements.

Only Part A pharmacists, and not interns or students, are authorized to prescribe the following:

  • Oseltamivir for treating influenza.
  • Nirmatrelvir/ritonavir for treating COVID-19.
    • Do not prescribe nirmatrelvir/ritonavir if the patient is at risk of any drug interactions that are contraindications or that cannot be properly managed.
    • Publicly funded nirmatrelvir/ritonavir must be prescribed in accordance with Ministry of Health requirements.

Adapting or Renewing a Prescription[2]

The pharmacist must be in possession of the prescription to be adapted or renewed, or

  • Obtain a copy of the prescription directly from the dispensing pharmacy.
  • Have verbal confirmation about the prescription from a pharmacist at the dispensing pharmacy.
  • Have access to the medical record that contains information about the prescription.

Pharmacists do not have the authority to renew or adapt a prescription for a controlled substance (narcotic, controlled drug and/or targeted substance) or a drug designated as a monitored drug by the regulations under the Narcotics Safety and Awareness Act, 2010.

Adapting

  • Pharmacists may adapt a prescription based upon the individual circumstances of the patient by altering the dose, dosage form, regimen or route of administration to address the patient’s unique needs and circumstances.
  • Adapting a prescription does not include therapeutic substitution; refer to Appendix B for more information.

Renewing

  • Pharmacists may renew a prescription for the purpose of continuity of care.
  • Pharmacists can only renew a quantity of the drug that does not exceed the lesser of:
    • The quantity that was originally prescribed, including any refills that were authorized by the prescriber; or
    • A twelve (12) month supply.

Before prescribing, pharmacists must:

1. Assess the patient

The pharmacist determines that the therapy is safe and appropriate by evaluating the risks and benefits, considering the patient’s health status and unique circumstances.

To inform their decision-making, the pharmacist should gather the available and relevant information necessary for this assessment, including (but not limited to):

  • Patient records (e.g., pharmacy profile, electronic health records).
  • Past medical history (e.g., medical conditions, medications or natural health products, allergies, intolerances).
  • Current medical history (e.g., indication/diagnosis, medications, signs and symptoms).
  • Physical characteristics (e.g., age, weight, height, pregnancy, lactation status).
  • Results of physical assessment, laboratory, point-of-care, or other tests.
  • Lifestyle (e.g., nutrition, exercise, substance use) and socioeconomic factors.
  • Anything reasonable to identify possible drug therapy problems, contraindications, or precautions.
  • For more information, please refer to the Patient Assessment Practice Tool.

Community pharmacies are strongly encouraged to enrol in one of the provincial clinical viewers (ConnectingOntario or ClinicalConnect) at no cost through Ontario Health.

  • Viewers provide a dynamic, near real-time view of patient’s health information (e.g., laboratory test results, dispensed medications covered by Ontario Drug Benefit, a history of publicly funded professional services) to enhance clinical decision making.

2. Assess their competency

The pharmacist must only prescribe when they can do so competently and safely by:

  • Possessing sufficient knowledge, skill and judgment respecting the drug1.
  • Having sufficient understanding of the condition of the patient1.
  • Having the resources necessary to meet their professional obligations and standards of practice.
  • Being of sound physical, emotional and mental capacity.
  • Addressing gaps or learning opportunities, identified through self- and/or peer-assessment, with continuing education and/or additional training.

Prior to prescribing for a minor ailment, the pharmacist must complete the mandatory OCP Orientation for Minor Ailments Prescribing e-Learning module and is expected to critically evaluate information from relevant, evidence-based sources to inform their clinical decision-making.

3. Assess the environment

Physical assessments must take place in an environment that is clean, safe, private, and comfortable for the patient, in a way that protects their confidentiality and dignity.

The Standards of Operation require pharmacy premises, facilities, and layout – along with equipment, technology and staffing – to support practice, to mitigate risks associated with the delivery of services, and to safeguard the health, safety and wellbeing of patients.

Community pharmacy owners and Designated Managers are expected to implement the Guiding Principles for Shared Accountability to support a suitable practice environment, which includes the physical working space as well as the practice culture, operating procedures, workflow, and resources available.

4. Obtain informed consent to treatment[3]

Prior to initiating a prescription, the pharmacist must receive informed consent from the patient or their authorized agent.

Under the Health Care Consent Act, consent to treatment is informed if, before giving it, the person received:

  • Information about the nature, expected benefit, potential risks or side effects of the proposed treatment.
  • Information about other options and consequences of not having the treatment.
  • Any information that a reasonable person in the same circumstances would require to make a decision about the treatment.
  • Responses to their request for additional information.

The information provided to patients to make informed decisions about their healthcare should be consistent with the best available clinical evidence.

  • Consent is contingent on an individual’s capacity to understand why and for what the consent is being sought.
  • There is no minimum age of consent in Ontario.
  • Consent may be express or implied.
    • Express consent may be provided by the patient in writing or provided verbally and documented by the pharmacist.
    • The pharmacist may determine that implied consent is provided, based on the patient’s action(s) or inaction in the circumstances at hand.

After deciding to prescribe, pharmacists must:

5. Issue the Prescription

The following information must be recorded on the prescription[4]:

  • Name and address of the patient.
  • Name, strength (where applicable), and quantity of the prescribed drug.
  • Directions for the use of the drug, including dose, frequency, route of administration, and any special instructions.
  • Name, address, telephone number, and College registration number of the pharmacist issuing the prescription.
  • Date the prescription was issued.
  • Number of refills authorized, if applicable.

6. Communicate & Educate

At the time of initiating, adapting or renewing a prescription, the pharmacist must advise the patient or their authorized agent that they are entitled to the prescription and may take it to a pharmacy of their choice for dispensing2.

Effective communication with patients and their healthcare team supports continuity of care and positive treatment outcomes. Pharmacists are expected to:

  • Communicate the rationale for their decision(s) (to prescribe, to refer, etc.).
  • Educate the patient on their treatment plan including any monitoring and/or follow-up required.
  • Collaborate with colleagues and other health care professionals to facilitate quality patient care.

7. Document & Notify

Document

When prescribing, the pharmacist must document in the patient record:

  • If applicable, reference to, or a copy of, the original prescription being renewed or adapted including the name and contact information of the prescriber[5].
  • A copy of the prescription taken by the patient or their authorized agent5, if applicable.
  • The rationale for the decision to initiate, adapt or renew the prescription (patient assessment, clinical guidelines consulted, etc.).
  • Results of any laboratory or other tests considered5.
  • Confirmation that informed consent was received.
  • Follow-up and monitoring plan.
  • Any other relevant details and/or recommendations.
  • The date that the original prescriber (and primary care provider if different) were notified, if applicable, and the method by which the notification occurred5.

Pharmacists are expected to adhere to the College’s Documentation Guideline. which describes how to meet the Standards of Practice for documentation (e.g., patient assessment, monitoring, follow up).

  • Documentation sent to other HCPs should be concise and include pertinent details respecting the pharmacist’s initiation, renewal or, if appropriate, adaptation of the prescription to ensure that the patient record is complete in all locations.
  • Documentation requirements for the provision of publicly funded services are established by the Ministry of Health.

Patients who do not have a primary care provider should be advised that they, or another health professional providing care to them in the future, are entitled to access this information at any time. Patients may also wish to have a copy of the documentation from their record for this purpose.

Notify

The pharmacist must notify the primary care provider or prescriber within a reasonable time after initiating1 or renewing a prescription2.

  • Notification of the prescriber is also required if a pharmacist has adapted a prescription in a manner that is clinically significant in the individual circumstances of the patient, or necessary to support the patient’s care 2.
  • If the patient’s primary health care provider is different from the original prescriber, they should also be notified in a reasonable time to ensure continuity of care2.
  • Notification requirements for the provision of publicly funded services are established by the Ministry of Health.
Legislative References:
Additional References:
External References:
Implementation

Published: December 2023
Version #: 6.00
College Contact: Pharmacy Practice

Revision History
VERSION # DATE ACTION
1.00 October 2012 Expanded Scope of Practice Orientation Manual.
2.00 February 2018 Guideline extracted from manual.
3.00 December 2020 Review, reformatting and inclusion of scope changes from O. Reg 202/94.
4.00 December 2022 Revised to include prescribing exemption for Paxlovid™ in O. Reg. 107/96.
5.00 January 2023 Revised to include prescribing for minor ailments.
6.00 December 2023 Addition of ‘pharmacist prescribing’ to title; addition of prescribing nirmatrelvir/ritonavir and oseltamivir to O. Reg. 202/94; minor content revisions.

 

APPENDIX A: Controlled Drugs and Substances Act (CDSA) Exemption

Health Canada has issued a Controlled Drugs and Substances Act (CDSA) subsection 56(1) class exemption to permit pharmacists to adapt and/or renew prescriptions for controlled substances for the purposes of facilitating continuation of treatment. The quantity prescribed/dispensed cannot exceed the amount originally authorized. Pharmacy interns and registered pharmacy students are not named in this exemption.

Please refer to the College’s Guidance – Providing a Prescription for Controlled Substances during the Coronavirus Pandemic for further information.

Appendix B: Therapeutic Substitution

Therapeutic substitution is defined in O. Reg. 202/94 as “the substitution of a drug that contains chemically different active ingredients that are considered to be therapeutically equivalent.” Therefore, the drug prescribed cannot be changed.

Pharmacists should exercise caution when changing the route of administration; an adaptation should not alter the pharmacokinetics or pharmacodynamics of the prescribed treatment if it leads to a clinically significant change of its therapeutic effect.

  1. O. Reg. 202/94, s35
  2. O. Reg. 202/94, s36
  3. Health Care Consent Act, PART II
  4. O. Reg. 202/94, s37
  5. O. Reg. 202/94 s38