Pennsylvania Code
Title 49 - PROFESSIONAL AND VOCATIONAL STANDARDS
Part I - DEPARTMENT OF STATE
Subpart A - PROFESSIONAL AND OCCUPATIONAL AFFAIRS
Chapter 16 - STATE BOARD OF MEDICINE-GENERAL PROVISIONS
Subchapter F - MINIMUM STANDARDS OF PRACTICE
Section 16.92 - Prescribing, administering and dispensing controlled substances

Universal Citation: 49 PA Code § 16.92

Current through Register Vol. 54, No. 12, March 23, 2024

(a) For purposes of this section, "drug" includes the following:

(1) Controlled substances under The Controlled Substance, Drug, Device and Cosmetic Act (35 P. S. §§ 780-101-780-144) or substances that are controlled substances under Federal law.

(2) Carisoprodol or agents in which carisoprodol is an active ingredient.

(3) Butalbital or agents in which butalbital is an active ingredient.

(4) Tramadol hydrochloride or agents in which tramadol hydrochloride is an active ingredient.

(b) When prescribing, administering or dispensing drugs regulated under this section, a person licensed to practice medicine and surgery in this Commonwealth or otherwise licensed or regulated by the Board shall carry out, or cause to be carried out, the following minimum standards:

(1) Initial medical history and physical examination. An initial medical history shall be taken and an initial physical examination shall be conducted unless emergency circumstances justify otherwise. Medical history and physical examination information recorded by another licensed health care provider may be considered if the medical history was taken and the physical examination was conducted within the immediately preceding 30 days. The physical examination shall include an objective evaluation of the heart, lungs, blood pressure and body functions that relate to the patient's specific complaint.

(2) Reevaluations. Reevaluations of the patient's condition and efficacy of the drug therapy shall be made consistent with the condition diagnosed, the drug or drugs involved, expected results and possible side effects.

(3) Patient counseling. The patient shall be counseled regarding the condition diagnosed and the drug prescribed, administered or dispensed. Unless the patient is in an inpatient care setting, the patient shall be specifically counseled about dosage levels, instructions for use, frequency and duration of use and possible side effects.

(4) Medical records. Accurate and complete medical records must document the evaluation and care received by patients.

(i) On the initial occasion when a drug is prescribed, administered or dispensed to a patient, the medical record must include the following:

(A) A specification of the symptoms observed by the licensed health care provider and reported by the patient.

(B) The diagnosis of the condition for which the drug is being given.

(D) The name, strength and quantity of the drug and the date on which the drug was prescribed, administered or dispensed.

(ii) After the initial occasion when a drug is prescribed, administered or dispensed, the medical record must include the information required in subsection (b)(4)(i)(D) and changes or additions to the information recorded under subsection (b)(4)(i)(A)-(C).

(5) Emergency prescriptions. In the case of an emergency contact from a known patient, a prudent, short-term prescription for a drug may be issued. Neither a refill nor a consecutive issuance of this emergency prescription may be given unless a physical examination and evaluation of the patient is first conducted by a licensed health care provider. The results of this examination and evaluation shall be recorded in the patient's medical record together with the diagnosis of the condition for which the drug is being prescribed. An emergency oral prescription for a Schedule II controlled substance shall be covered by a written prescription delivered to the pharmacist within 72 hours.

(6) Compliance with other laws.

(i) This section may not be construed as restricting or limiting the application of The Controlled Substance, Drug, Device and Cosmetic Act or statutes or regulations of the Department of Health and the Department of Public Welfare that govern the prescription, administration and dispensation of drugs and medical recordkeeping in certain health care facilities.

(ii) This section may not be construed as restricting or limiting the application of Federal laws or regulations that govern the prescription, administration and dispensation of drugs and medical recordkeeping in certain health care facilities.

(iii) This section does not relieve a person from complying with more stringent standards that may be imposed by another statute or regulation.

(7) Compliance with facility policy. This section does not relieve a person from complying with more stringent standards that may be imposed by the health care facility in which the person practices or by the person's employer.

(8) Adherence to standards of practice. Compliance with this section will not be treated as compliance with the standards of acceptable and prevailing medical practice when medical circumstances require that the licensed health care provider exceed the requirements of this section.

The provisions of this § 16.92 amended under section 8 of the Medical Practice Act of 1985 (63 P. S. § 422.8).

This section cited in 49 Pa. Code § 18.6a (relating to prescribing, dispensing and administering drugs); 49 Pa. Code § 18.157 (relating to administration of controlled substances and whole blood and blood components); and 49 Pa. Code § 18.158 (relating to prescribing and dispensing drugs, pharmaceutical aids and devices).

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