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Policies,Administrative,UWHC,Department Specific,Pharmacy,Administration

Pharmacy Retention Records (1.23)

Pharmacy Retention Records (1.23) - Policies, Administrative, UWHC, Department Specific, Pharmacy, Administration

1.23

POLICY & PROCEDURE





Effective Date:
October 2000
⌧ Pharmacy Policy Manual
Chapter: Administration
Operations Procedure Manual
Chapter:

Policy #: 1.23

… Original
⌧ Revision 5/14
Page 1
of 4
Title: Pharmacy Records Retention



I. PURPOSE: To establish guidelines and timelines for the retention and/or destruction of
Pharmacy Department records.

II. POLICY: The following guidelines and timelines must be followed by Pharmacy Department
personnel when storing pharmacy records. The guidelines and timelines are in accordance with
federal, state and hospital regulations.

III. PROCEDURE:
A. The department records storage coordinator will be responsible for retaining all
documents in designated department storage and sending documents to the Data keep.
1. Coordinator will maintain a 3-ring binder in the pharmacy office with all
documents going to and from Data keep and other pertinent information.
2. Coordinator will control the key for C5/103 and monitor all boxes of documents
going into and out of C5/103.
B. Boxes for storing documents can be ordered from Office Max.
1. Each area of the department in the hospital and the off site clinics are responsible
for properly labeling the boxes as to what documents are inside and the dates the
documents cover (i.e. Prescriptions from University Station June 1, 2008- June
30, 2009)
2. Each area of the department in the hospital and the off-site clinics must contact
the department records storage coordinator at 263-1290 when storage boxes are
needed and when they have boxes of documents ready to be sent to designated
department storage or to Data Keep.
C. The department records storage coordinator will be responsible for coordinating transfer
of boxes either to designated department storage or to Data Keep.
D. Data Keep will have monthly pickups on the 1st Friday of each month. The department
records storage coordinator will be responsible for coordinating boxes for pickup,
retrieval, and resend from Data Keep as per procedures in the Data Keep record user
guide found in the red 3 ring binder of document storage and retention information kept
in F6/133.
E. Department records coordinator will also be responsible for ordering necessary forms, bar
code labels, etc. and maintaining records storage and retention book.
F. Specific Pharmacy Department documents and storage requirements are listed in the
following table:

Specific Pharmacy Department Documents and Storage Requirements

2

Type Document Storage Requirements
A
d
m
i
n
i
s
t
r
a
t
i
v
e

S
c
h
e
d
u
l
i
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Pharmacist schedules Retain electronically for 1 year per contract with
ScheduleRx.
Pharmacist bi-weekly leave
reports
Retain on file for 1 year in pharmacy administrative office
and then recycle.
Inpatient pharmacist
vacation requests
Retain electronically through ScheduleRx for 1 year.
Ambulatory, CDP, PRC
pharmacist vacation
requests
Retain for 5 years then recycle.
Technician time cards Retain electronically through ReportXpress for an indefinite
amount of time.
Technician vacation
requests
Retain for 5 years then recycle.
Technician schedules Retain electronically for an indefinite amount of time.
A
m
b
u
l
a
t
o
r
y

P
a
t
i
e
n
t

R
e
c
o
r
d
s

Patient profiles Retain electronically for an indefinite amount of time.
Prior authorization forms Retain at respective sites for 1 year and then destroy.
Medical information
release signatures
Signatures granting the release of medical information
should be faxed to Fiscal Department/Sally Johnson and
Patti Seifriz (608-263-5657) for documentation. Hard copies
should also be sent to Fiscal.
L
e
g
a
l

Prescriptions Retain both controlled and non-controlled prescriptions for 6
months at respective sites and then send to Data Keep;
destroy after 10 years. See Policies 7.5 and 7.14 for
controlled substances.
Schedule II controlled
substances
Each pharmacy site shall maintain a complete and accurate
written perpetual inventory record for the receipt and
disposition of all C-II medications. All records
(prescriptions, DEA Form 222, CSOS receiving documents,
perpetual inventory logs, and discrepancy reports) shall be
retained at the respective site for 6 months or until storage
box is full (whichever occurs first) and then sent to Data
Keep to be stored; destroy after 10 years. C-II medication
records should be maintained separate from all other records.
See Policies 7.5 and 7.14 for controlled substances.
Medication owe log Retain medication owe log (partial fills) for 1 year at
respective sites and then send to Data Keep; destroy after 10
years
Schedule V sale log Retain schedule V sales log (OTC codeine) at respective
sites for 1 year and then send to Data Keep; destroy after 10
years
Pseudoephedrine records Retain electronically through Emporos for an indefinite
period of time. Paper records kept when errors occur in
Emporos should be retained at respective sites for 1 year and
then sent to Data Keep; destroy after 10 years
A u r a
Clinic charges Retain at respective site for 6 months and then send to Data

Specific Pharmacy Department Documents and Storage Requirements

3
Type Document Storage Requirements
Keep; destroy after 3 years
Shipping & tracking logs
(Mail Order prescriptions)
Shipping and tracking logs printed from UPS and priority
mail should be stored at respective sites for 1 year then
destroyed. Additionally, UPS tracking forms may be
available electronically through UPS for an indefinite period
of time.
Shipping notebooks Retain one notebook for current use and one full notebook
containing the most recent past shipping labels at East/Mail
Order pharmacy for records. Once current notebook
becomes full, destroy oldest notebook and start using a new
notebook. East/Mail Order pharmacy should always have
one current notebook for shipping label use and one old
notebook of the most recent past labels kept on site.
Delivery signatures
(Mail Order prescriptions)
Retain at East/Mail Order pharmacy for 3 months or until
box is full then send to Data Keep; destroy after 10 years.
Patient counseling and
insurance logs
Hard copies: Retain for 6 months in designated department
storage then send to Data Keep; destroy after 7 years.
Electronic copies: Retain for an indefinite amount of time.
T
J
C

Refrigerator logs Store at respective sites for 1 year and then send to Data
Keep; destroy after 3 years.
Expiration date checking
records
Retain at respective sites for 1 year and then send to Data
Keep; destroy after 3 years.

Call logs Retain at respective sites for 1 week then destroy.

McKesson invoices Retain at respective sites for 6 months then destroy.

Daily task lists Retain at respective sites for 1 month then destroy.
Additionally, task lists should be faxed to main pharmacy
office (608-263-9424) to be reviewed by ambulatory
pharmacy manager and then destroyed.

Syringe purchase log Retain at respective sites for 1 year and then send to Data
Keep; destroy after 10 years.

Cash-out records Retain at respective sites for 1 year then destroy.

Cash bag delivery log Retain at respective sites for 1 year (file with cash-out
records) then destroy.

Patient enrollment forms
(Mail Order)
Patient enrollment forms should be scanned and stored
electronically on the J: drive for an indefinite amount of
time. Paper forms should be stored at respective sites for 1
year then destroy.

ADAP certification Forms should be faxed to Fiscal Department/Sally Johnson
and Patti Seifriz (608-263-5657) for documentation. Hard
copies should also be sent to Fiscal.
I
n
p
a
t
i
e
n
t

C
e
n
t
r
a
l

IV preparation records Retain for 6 months in designated department storage then
send to Data Keep; destroy after 6 years.
Sterile products area log
books
Retain for 6 months in designated department storage then
send to Data Keep; destroy after 6 years.
Monthly statistics Central pharmacy workload reports should be sent to records
coordinator to retain in department storage for 1 year then
destroy.

Specific Pharmacy Department Documents and Storage Requirements

4
Type Document Storage Requirements
I
n
p
a
t
i
e
n
t

C
e
n
t
r
a
l

TPN reports TPN reports should be stapled together each day and kept in
the file bin in SPA for the week and then will be stored in
designated department storage. Retain in department storage
for 6 months the send to Data Keep; destroy after 6 years.
SPA stock reports SPA stock production reports will be retained in designated
department storage for 6 months then send to Data Keep;
destroy after 6 years.
Controlled substance
records
DEA form 222, CSOS forms, OR and Clinic medication
records (prepared by SPA): Retain for at least 6 months in
designated department storage then send to Data Keep;
destroy after 5 years.

Inpatient profiles/charges Retain electronically in Health Link for an indefinite amount
of time.
P
u
r
c
h
a
s
i
n
g


Purchasing records Once purchase orders (POs) are matched with packing slip
send to Accounts Payable who will match to invoice for
payment and then send to Data Keep. Purchasing records can
be retrieved electronically from Peoplesoft and McKesson
SMO as well.

Issues reports – source
documents
Daily pick lists, receipt documents, Order Rx, Peoplesoft
reports – retain for 1 year in department storage then destroy.
Order Rx and Peoplesoft reports can also be retrieved
electronically for an indefinite period of time.

Medication purchase
invoices/ stockroom
receipts
Retain for 1 year in pharmacy department then destroy.
M
i
s
c
.


Charge Forms Second copy of inpatient and outpatient charge forms
(including 609, 779, 77, 937, OR, RR, Cath, Renal,
Ambulatory, ED): Retain 6 months in designated department
storage then send to Data Keep; destroy after 3 years.

Billing Audits Retain for 6 months in designated department storage then
send to Data Keep; destroy after 3 years.


IV. REFERENCES AND RELATED POLICIES, PROCEDURES
A. Pharmacy Policy 7.5 – Controlled Substances – Record Keeping
B. Pharmacy Policy 7.14 – Schedule II Controlled Substance Procedures for Ambulatory
Pharmacies


Approved By: ____________________________
Director of Pharmacy Services

Date: ____________


XC: Ambulatory Pharmacy P&P Book