Know and understand characteristics and uses of patient records, pharmacy records

Resources → Subject Notes → Information Communication Technology ICT → Lesson Plan
ICT 0417 – 6 ICT Applications: Patient and Pharmacy Records

6 ICT Applications – Patient Records and Pharmacy Records

Learning Objective

Know and understand the characteristics and uses of patient records and pharmacy records.

1. Patient Records

1.1 Characteristics

Characteristic Description
Confidentiality Access is restricted to authorised personnel only; data is encrypted and password‑protected.
Accuracy Information must be up‑to‑date, verified and free from errors.
Completeness All relevant clinical information (diagnosis, treatment, test results, allergies) is recorded.
Standardised format Uses agreed codes (e.g., ICD‑10 for diagnoses, SNOMED CT) to allow easy sharing.
Audit trail System logs who accessed or modified the record and when.
Interoperability Can be exchanged between hospitals, labs, and primary‑care centres using HL7 or FHIR standards.

1.2 Uses

  • Clinical decision‑making – provides doctors with a complete history to guide treatment.
  • Medication safety – alerts for drug interactions and allergies.
  • Appointment scheduling – links patient records with calendar systems.
  • Billing and insurance claims – supplies required diagnostic codes.
  • Research and audit – anonymised data can be analysed for public‑health trends.
  • Legal evidence – serves as a documented record of care provided.

2. Pharmacy Records

2.1 Characteristics

Characteristic Description
Stock control Tracks quantities of each medicine, batch numbers and expiry dates.
Prescription linkage Each dispensed item is linked to a specific patient prescription.
Regulatory compliance Meets legal requirements for controlled substances (e.g., record‑keeping periods).
Security Access limited to authorised pharmacy staff; uses user IDs and passwords.
Audit trail Logs dispensing events, adjustments, and returns.
Integration Connects with patient record systems and external suppliers for ordering.

2.2 Uses

  • Dispensing – ensures the right drug, dose and instructions are given to the patient.
  • Inventory management – alerts when stock is low or medicines are near expiry.
  • Prescription verification – checks for drug interactions with existing patient medications.
  • Billing – generates invoices for patients or insurance providers.
  • Regulatory reporting – produces required reports for health authorities.
  • Clinical audit – analyses dispensing patterns to improve safety and efficiency.

3. Relationship Between Patient and Pharmacy Records

Effective ICT systems link patient records with pharmacy records to create a seamless flow of information:

  1. Doctor enters a prescription into the patient’s electronic health record (EHR).
  2. The prescription is transmitted securely to the pharmacy system.
  3. The pharmacy checks the patient’s medication history for interactions.
  4. After dispensing, the pharmacy updates the patient record with details of the medication supplied.
  5. Both systems maintain an audit trail for accountability.

4. Key Benefits of Using ICT for These Records

  • Improved patient safety through real‑time alerts.
  • Reduced paperwork and faster access to information.
  • Enhanced accuracy and consistency of data.
  • Better resource management in pharmacies.
  • Facilitates compliance with legal and professional standards.
Suggested diagram: Flow of information between patient records, pharmacy records, and external systems (e.g., labs, insurers).