General Prescribing and Ordering Standards for Controlled Substances


  1. Prescribe and order therapeutics within their scope of practice, and in compliance with relevant federal and provincial legislation and organizational policies.
  2. Are accountable for their prescribing decisions.
  3. Prescribe and order therapeutics according to best evidence.
  4. Before prescribing and ordering, ensure they are competent to:
    1. establish or confirm a midwifery diagnosis for the client;
    2. manage the treatment and care of the client; and
    3. monitor and manage the client’s response to the therapeutic.
  5. When prescribing and ordering therapeutics:
    1. consider the client’s health history and other relevant factors (e.g. age, gender, lifestyle, the client’s perspective);
    2. undertake and document an appropriate clinical evaluation (e.g. physical examination, review of relevant tests, imaging and specialist reports);
    3. obtain and document the best possible medication history for the client using PharmaNet (when access is available) and other sources;
    4. review and document the medication history and act to address any discrepancies;
    5. ask about the client’s drug allergies and ensure drug allergy information is accurate and documented;
    6. appropriately document the therapeutic prescribed and their indication(s) in the client’s medical record;
    7. establish and document a plan for reassessment/follow-up; and
    8. monitor and document the client’s response to the therapeutic prescribed (as appropriate).
  6. When prescribing, provide information to clients about:
    1. potential benefits and risks of the therapeutic;
    2. the expected action of the therapeutic;
    3. the duration of therapy;
    4. specific precautions or instructions for the therapeutic;
    5. potential side-effects and adverse effects and action to take if they occur;
    6. potential interactions between the therapeutic and certain foods, other substances, or substances; and
    7. recommended follow-up.
  7. Complete prescriptions and orders accurately and completely, including:
    1. the date the prescription was written;
    2. client name, address (if available), PHN (if available) and date of birth;
    3. client weight (if required);
    4. name, strength and dose of the controlled drug;
    5. the quantity prescribed and quantity to be dispensed (prescriptions);
    6. dosage instructions (i.e. frequency or interval, maximum daily dose, route of administration, duration of therapy);
    7. their name, address, telephone number, written (not stamped) signature, and CMBC registration number;
    8. date of transmission, the name and fax number of the pharmacy intended to receive the transmission, and their fax number if the prescription is being faxed; and
    9. directions to the pharmacist not to renew or alter.
  8. Document all written, verbal and telephone orders accurately, contemporaneously and legibly in the client record.
  9. Undertake medication reconciliation as required by the Health Authority to ensure accurate and comprehensive medication information is communicated consistently.
  10. Report adverse drug reactions to the Canada Vigilance Program[1].
  11. Manage, document, report and disclose any medication errors.
  12. Prescribe only for clients except in emergency situations when there is no other prescriber available, within scope.
  13. Do not provide anyone with a blank, signed prescription.

[1]Health Canada’s surveillance program that collects and assesses reports of suspected adverse reactions to health products marketed in Canada.