OAR 855-041-1165: Patient Medical Record

A patient record system must be maintained by pharmacies for all patients for whom prescription drug orders are dispensed. The patient record system must provide for readily retrievable information necessary for the dispensing Pharmacist to identify previously dispensed drugs at the time a prescription drug order is presented for dispensing. The Pharmacist must make a reasonable effort to obtain, record, and maintain the following information: (1) Full name of the patient for whom the drug is intended; (2) Address and telephone number of the patient; (3) Patient's date of birth; (4) Patient's gender; (5) Patient’s preferred language for communication and prescription labeling; (6) Chronic medical conditions; (7) A list of all prescription drug orders obtained by the patient at the pharmacy maintaining the patient record showing the name of the drug or device, prescription number, name and strength of the drug, the quantity and date received, and the name of the prescriber; (8) Known allergies, drug reactions, and drug idiosyncrasies; and (9) If deemed relevant in the Pharmacist's reasonable professional judgment: (a) Pharmacist comments relevant to the individual's drug therapy, including any other information peculiar to the specific patient or drug; and (b) Additional information such as chronic conditions or disease states of the patient, the patient's current weight, and the identity of any other drugs, including over-the-counter drugs, or devices currently being used by the patient which may relate to prospective drug review.