Standards for the management of controlled stationary related to medicines

1 Aim

The aim of this document is to set down the standards for the management of controlled stationary related to medicine.

2 Link to overarching policy and, or procedure

This document links to the overarching safe and secure handling of medicines manual.

3 Definition

The following documents are considered controlled stationary Inpatient drug charts:

discharge or leave forms
community drug charts, including depot cards
controlled order and record books
invoices
inpatient stock or non-stock order pads
FP10 or FP10, NC or FP10SS and MDA forms

Inpatient documentation should be kept securely on the ward, so only authorised staff have access.

Where more than one pad or book exists it should be clear which is in current use.

The responsible person will ensure that all controlled stationery on the ward, department or base point is held securely.

Any loss or theft of any item of controlled stationery will be reported to the responsible person for the ward or department and their line manager, and to the trust chief pharmacist at the earliest opportunity. An incident form (IR1) must be completed.

4 Retention of documents

The healthcare record keeping policy must be adhered to.

5 FP10, FP10 NC, FP10SS and MDA prescription pads

Prescribers seeing patients in the community will have access to a supply of FP10s which are written by prescribers employed by the trust but dispensed by community rather than hospital pharmacies.

Controlled stationery in relation to prescribing includes blank FP10NC, FP10MDA and FP10SS prescriptions, prescription stamps and prescription order forms.

Ordering of blank prescriptions can only be undertaken by authorised personnel and must be ordered from the appropriate, for the area, supplier.

They are classed as controlled stationary.
Must be signed for when ordered by administrative staff.
Prescription numbers must be recorded, see section 8 for computer generated prescriptions.
Locked away securely.
A record of receipt must be maintained.
When issued to individual prescribers they must be signed for and a record kept including the prescription number.
Prescribers should keep them in a manner so that they are secure when not in use, and should only carry sufficient that would be required at any point in time.
In substance misuse services where prescription printing software is in use, access to these systems must be secure.
Where prescriptions are spoilt, they must be marked void, before being securely shredded, and a record made.
Prescriptions issued to prescribers must be signed for and a record kept. It is the responsibility of the prescriber for their safe keeping.

6 Issuing FP10 prescriptions

Prescriptions once generated may be issued in one of the following ways:

directly to the patient or representative
recorded delivery to the patient’s address
by staff to the pharmacy
collection by the pharmacy staff
sent electronically using SystmOne by electronic transfer of prescription protocol

In all situations staff must be satisfied of the authorisation of any carrier and identification must be sought. A record of all prescriptions issued must be maintained in the patient record.

7 Prescribers leaving the trust or moving departments

When a prescriber moves jobs, they should return any existing prescriptions pads they have to the administrative staff they originally received them from. A cease to prescribe form must be completed, this can be found within the non-medical prescribing policy.

8 Computer generated FP10’s (paper versions)

Ensure that the prescriptions are stored securely, and if they are to be kept in the printer that this is located in a secure environment.
When loading the printer with the prescriptions make a note of the serial number of the first prescription.
When removing the unused prescriptions make a record of the serial number of the next prescription.

9 Lost prescription pads

In the event of a lost or stolen prescription or prescription pad all prescribers should:

inform their line manager the same day
complete an incident form (IR1)
inform the chief pharmacist or medical director who will alert all pharmacies and liaise with the police and the prescribing pricing authority providing information including serial numbers
the prescriber will be advised to write all prescriptions in red ink for the next 2 months

If the loss occurs out of hours contact the out of hours on call director and implement the following procedure:

notify the police
staff would then follow the in hours process on the first routine working day, this action should be completed by the manager to whom this has been reported to

10 Standard operating procedure (SOP) for FP10’s

All areas should have a specific standard operating procedure for managing these prescriptions, which will contain the details on how these standards will be carried out. Please refer to the management of medicines on hazel, hawthorn and magnolia wards SOP.

Document control

Version: 2.
Unique reference number: 558.
Approved by: Clinical policy review and approval group.
Date approved: 4 July 2023.
Name of originator or author: Senior pharmacist.
Name of responsible individual: Executive medical director.
Date issued: 1 August 2023.
Review date: 31 August 2026.
Target audience: Trust wide.
Description of change: Document review.

Page last reviewed: September 13, 2024
Next review due: September 13, 2025

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