Contents
- Aim
- Link to overarching policy and, or procedure
- Definition
- Retention of documents
- Prescription pads
- Issuing FP10 prescriptions
- Prescribers leaving the trust or moving departments
- Computer generated FP10’s (paper versions)
- Lost prescription pads
- Standard operating procedure for FP10’s (prescriptions)
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 nonstock order pads
- FP10 (NHS prescription) or FP10NC (NHS prescription, non-computerised) or FP10SS (NHS prescription, single sheet) and F10MDA (medication dispensing authority) forms
Documentation should be kept securely, so only limited authorised staff have access.
Where more than one pad or book exists it should be clear which is in current use. Only one pad or book should be in use at a time
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 Prescription pads
Prescribers seeing patients in the community will have access to a supply of FP10s (NHS prescriptions) which are written by prescribers employed by the trust but dispensed by a community pharmacy rather than hospital pharmacies.
Controlled stationery in relation to prescribing includes blank FP10NC (NHS prescription, non-computerised), FP10MDA (medication dispensing authority) and FP10SS (NHS prescription, single sheet) 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 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 with restricted access.
- A record of receipt must be maintained.
- When issued to individual prescribers they must be signed for and a record kept including the prescription numbers.
- 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.
- Prescriptions must be visible in the patients record. If this is a handwritten prescription, a record of all team prescriptions issued must be maintained on the FP10 tracker and in the patients record. The prescription can be scanned onto the patient record.
- 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, a record made before being securely shredded.
- This is a two-person process.
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 community 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 from a team prescription pad must be maintained on the FP10 tracker and in the patient record.
7 Prescribers leaving the trust or moving departments
When a prescriber moves jobs, they should return any existing prescription pads they have to the administrative staff. 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. They must not be stored in a printer overnight and must be returned to the secure location.
- 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 for FP10’s (prescriptions)
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 following links depending on the area of work.
Links for each service:
- Community controlled stationary at a glance (staff access only) (opens in new window)
- Inpatient FP10 prescriptions at a glance (staff access only) (opens in new window)
Document control
- Version: 2.1.
- Unique reference number: 558.
- Ratified by: Clinical policy review and approval group.
- Date ratified: 7 January 2025.
- Name of originator or author: Medicine management committee.
- Name of responsible individual: Medical director.
- Date issued: 13 January 2025.
- Review date: 31 August 2026.
- Target audience: Trust wide.
- Description of change: Added links to inpatient FP10 prescriptions at a glance and community controlled stationary at a glance.
Page last reviewed: February 19, 2025
Next review due: February 19, 2026
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