Prescribing Decision & Record-Keeping SOP

What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

• Purpose
• 1. Record contemporaneously
• 2. The minimum record
• 3. Recording the reasoning
• 4. Recording a decline properly
• 5. Repeat and continuing supply
• 6. Language
• 7. Storage, access and retention
• 8. Audit
• 9. Related documents
• 10. Document control

CQC fundamental standard

Legislation & standards it maps to

• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - in particular Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 20 (Duty of candour)
• Human Medicines Regulations 2012 (as amended)
• General Pharmaceutical Council standards for pharmacy professionals
• Data Protection Act 2018 and the UK General Data Protection Regulation
• Limitation Act 1980

Who it applies to

All prescribers and clinical staff making entries in the clinical record at [Organisation Name]

How it works

1. Buy securely with Stripe - instant, no VAT, no account needed.
2. Download your editable Word file from the link we email you straight away.
3. Complete the placeholders for your service, then have it approved before use.
4. Add the optional updates subscription and we keep it current as guidance changes.