Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 5 – Pharmacy and Medication Services

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3.5.8 Prescription/Order Requirements and Medication Availability

  • Policy

    • California Correctional Health Care Services (CCHCS) shall provide prescribed medications accurately and timely to patients within California Department of Corrections and Rehabilitation (CDCR).  The general principles of medication administration in this policy and corresponding sections apply to all medication administration settings, both inpatient and outpatient.

  • Procedure Overview

    • Medication prescriptions/orders shall be prescribed/ordered by licensed health care providers who are credentialed by CCHCS and are authorized to prescribe or issue medication prescriptions/orders within their scope of practice.  To the extent permitted by law, all valid unexpired prescriptions/orders written by CCHCS providers shall be honored by CCHCS health care staff, including health care staff in CDCR institutions other than where the prescription/order originated.  Providers authorized by law to prescribe/order medications shall evaluate current prescriptions/orders of patients prior to the expiration date of the prescriptions/orders.

  • Purpose

    • To ensure medications prescribed/ordered by appropriately licensed and credentialed health care providers are dispensed and administered in accordance with all applicable laws and regulations.

    • To ensure continuity of care when patients are transferred between CDCR institutions.

    • To standardize the values, units of measurements, computations, abbreviations, and chemical symbols used in the prescribing/ordering and labeling of medications and prescriptions/orders within CCHCS.

  • Responsibility

    • Statewide

      • CCHCS and CDCR departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative and clinical systems are in place and appropriate tools, training, technical assistance, and levels of resources are available so that licensed health care staff can successfully apply this procedure.

    • Regional

      • Regional Health Care Executives are responsible for ensuring adherence to this policy at the subset of institutions within their assigned region.

    • Institution

      • The Chief Executive Officer, or designee, is responsible for the application, monitoring, evaluation of and compliance with this procedure.

      • The institutional Chief Medical Executive, Chief Psychiatrist, Supervising Dentist, Chief Nurse Executive, and Pharmacist-in-Charge shall maintain a multidisciplinary approach to ensure compliance with this procedure.

  • Procedure

    • Prescription/Order Requirements

      • Medications shall be dispensed/furnished pursuant to prescriptions/orders or system-wide approved protocols and standing orders where health care staff are authorized by the scope of their practice and the staff has been credentialed by CCHCS.

      • Prescriptions/orders shall be limited to the medications listed in the CCHCS Drug Formulary, as clinically appropriate as most of these medications will be readily available.

        • Nonformulary medication orders shall be processed in accordance with the Health Care Department Operations Manual (HCDOM), Section 3.5.5, CCHCS Drug Formulary.

      • Appropriate efforts shall be made to utilize drug regimens approved by the Food and Drug Administration for the prescribed indication and the prescribed dosage before prescribing a medication off-label. Medications for off-label use may be prescribed based on sound scientific evidence, expert medical judgment, or peer reviewed published literature.

        • The provider who prescribes an off-label medication shall exercise clinical judgment based on scientific literature.  The provider is responsible for deciding which medication to use, the medication dosing regimen, and the indication for use for each patient.

        • When requested by the pharmacist, the prescriber shall provide supporting literature and clinical reasoning to the pharmacist prior to dispensing the prescription.

      • All prescriptions/orders for medication shall be entered via computerized provider order entry (CPOE). In addition, all prescriptions/orders for Drug Enforcement Administration (DEA) controlled substances shall be signed utilizing the approved DEA-certified electronic prescription application.

        • If CPOE is unavailable:

          • The prescription/order shall be legibly typed or handwritten on a CDC 7221, Physician’s Orders, signed by the prescribing/ordering provider, and shall also include the prescriber’s printed name and title, or personal rubber stamp identifying their name and title.

          • The prescription/order may be faxed to the pharmacy.  Faxed orders shall be marked “Faxed” on the copy sent to the pharmacy.  The notation should include the time and date faxed.

          • Follow downtime recovery procedures to enter orders into the Electronic Health Record System (EHRS) as soon as functionality returns.

          • DEA-permitted verbal and written prescriptions, as described in HCDOM, Section 3.5.9, DEA Schedule II-V Controlled Substances, shall only be used when the provider lacks electronic access.

      • CCHCS may utilize standing orders approved by the Systemwide Pharmacy and Therapeutics (P&T) Committee.  Standing orders include, but are not limited to:

        • Routine vaccination and preventative health.

        • Medications deemed necessary across the patient population with specified criteria.

      • All medications shall be ordered Keep-on-Person (KOP) unless the prescriber determines that they cannot be safely or properly self-administered or unless the medications are required by policy to be Nurse Administered (NA) or Directly Observed Therapy (DOT).

        • The prescriber’s decision that medication be administered NA or DOT, due to safety reasons, may be informed by notifications from Mental Health or through consultation with Mental Health. 

        • For patients in outpatient housing units and Restricted Housing Units, all rescue inhalers, nitroglycerin, and oral glucose shall be prescribed and dispensed as KOP, unless the prescriber specifically orders NA due to strong clinical justification to do so (e.g., physical or mental inability to self-administer or danger to self).  The clinical justification shall be documented in the health record and shall be based upon information contained in the health record or upon results from the formal mental health consultation addressing mental health barriers to self-administration of medication.  

        • Medications prescribed for mental health indications shall not be prescribed KOP with the exceptions specified on the KOP-Permitted Mental Health Medication List. 

        • All oral DEA controlled substances, except those used in the treatment of substance use disorder and approved for KOP by the Systemwide P&T Committee, shall be prescribed DOT; refer to the HCDOM, Section 3.5.29, Medication Administration, for rules and exceptions.

        • Other recommendations on selecting an administration type are available on Lifeline: https://cdcr.sharepoint.com/sites/cchcs_lifeline_pharmacy/SiteAssets/SitePages/Best-Practices/kopnadot-recommendations.pdf

      • When initiating a new medication, if clinically appropriate, the prescriber should include a start date two days into the future to allow time for the pharmacy to process the order and the Central Fill Pharmacy to fill the order. 

      • When prescribing medications, the prescriber shall explain to the patient how to take the medication (prescription instructions) and when medications are permitted to be kept on their person at all times including during transportation as specified on the Rescue Medications list.  The prescriber shall ensure that effective communication is provided and appropriately documented.

      • Prescriptions/orders shall include:

        • Generic name of medication.

        • Dosage.

        • Specific directions for use.

        • Route of administration.

        • Frequency of administration.

        • Time and date of prescription/order.

        • Duration of therapy in days, doses, hours, minutes, or weeks.

        • Patient’s name, CDCR number, date of birth, and housing location (as applicable).

        • Drug allergies.

        • Administration status (e.g., KOP, NA, DOT).

        • Number of days supply of KOP medications per dispense, if other than 30 days.

        • Language required (if other than English).

        • Indication for use when medication is ordered as needed (PRN) or where formulary restrictions require the indication to be provided on the order.

        • Prescriber’s signature and either the prescriber’s printed name or personal rubber stamp.

      • Prescriptions/orders missing elements shall be returned to the prescriber for completion before verification by the pharmacist pursuant to EHRS Clinical Leadership Advisory Committee Approved Workflows, Workflow 700-210, Pharmacy, Incomplete and Clarification Workflow. 

      • In the event that EHRS is not available, health care staff shall screen prescriptions/orders to the extent possible for inclusion of the required elements of a prescription/order before transmitting the prescription/order to the pharmacy.

      • Prescriptions/orders for PRN medications shall be written as explicitly as possible and shall include the following:

        • Indication for use.

        • One specific dose and dosing criteria per prescription/order.  If more than one dose is necessary (e.g., take one tablet for moderate pain and two tablets for severe pain), then multiple prescriptions/orders are required.

      • Specific frequency (e.g., every eight hours); range frequency shall not be used (e.g., every four to six hours). 

      • Medication prescribed with PRN directions for which there is clear pharmacologic rationale requiring it to be administered on a scheduled basis shall be clarified by the pharmacist with the prescriber.  It is unacceptable to inappropriately prescribe for PRN administration a medication which requires regularly scheduled administration for efficacy simply to avoid noncompliance notifications.

      • Over-the-Counter (OTC) Medications:

        • An OTC Canteen is available to ensure all incarcerated persons have equal access to OTC products without cost or the need for nurse protocol or a prescription, pursuant to the HCDOM, Section 2.1.3, Over-the-Counter Products.

      • For policies and procedures regarding prescribing DEA controlled substances, criteria relevant to the prescribing/ordering of DEA controlled substances including those used for substance use disorder treatments, refer to the HCDOM, Section 3.5.9, DEA Schedule II-V Controlled Substances.  All pharmacists have the responsibility to ensure that DEA controlled substances prescriptions/orders have been issued by appropriately authorized providers.

    • Additional Requirements for Mental Health Medications

      • Mental health medications, which only include those written by a psychiatrist or a psychiatric nurse practitioner (working under the supervision of a psychiatrist) for a mental health indication, are to be prescribed/ordered as NA or DOT with the exceptions specified on the KOP-Permitted Mental Health Medication List.

      • KOP may be permissible for some medications used for symptomatic relief or as part of a prophylactic regimen (e.g., laxatives for clozapine) when written by a psychiatrist.  These medications are specified in the CCHCS Drug Formulary or the Systemwide P&T Committee communications.

    • Use of Abbreviations

      • The use of abbreviations in prescriptions/orders increases the risk of medication errors and should be limited to the extent possible.

      • Abbreviations that may be used include:

        • KOP, DOT, and NA

        • Standardized Latin such as PR (rectally), PRN (as needed), OU (each eye), BID (twice a day), and TID (three times a day)

      • A list of nationally recognized, high-risk abbreviations which should not be used is located on Lifeline’s Pharmacy page: https://cdcr.sharepoint.com/sites/cchcs_lifeline_pharmacy/FormsMedLists/Do-Not-Use-List-of-Abbreviations.pdf

      • Chemical symbols shall not be used in prescriptions/orders except where authorized by the Systemwide P&T Committee.

    • Use of Metric System

      • Prescriptions/orders and prescription labels shall contain the dose in metric units.

      • Prescriptions/orders with a decimal shall include a leading zero (e.g., 0.2 mg not .2 mg) but shall not include a trailing zero (e.g., 2 mg not 2.0 mg).

    • Tablet-Splitting

      • To the extent possible if clinically appropriate, prescriptions/orders shall be written to refrain from splitting tablets.  When appropriate, pharmacists shall select products, suggest alternative medications to providers, and recommend dosing changes to minimize splitting tablets. 

      • Where a half tablet is necessary, the pharmacist shall select a scored product for easier and more consistent administration.

      • If a pill cutter is required for the dose, the medication shall be administered as an NA or DOT, and a patient-specific pill cutter shall be issued by the pharmacy to the nursing staff.  A pill cutter shall not be allowed in the possession of patients.

    • Telephone/Verbal Prescriptions/Orders Excluding DEA Controlled Substances

      • Telephone/verbal prescriptions/orders shall be kept to a minimum and shall be received only by licensed nursing staff, and other licensed staff consistent with the scope of their practice. 

      • The staff receiving the telephone/verbal prescription/order shall enter the prescription/order via CPOE or write down the prescription/order on the CDC 7221.  The staff shall then read back the prescription/order, allowing the provider to validate the correct transcription.  The staff transcribing an order to the CDC 7221 shall indicate “phone with read back” or “verbal with read back” and shall sign the transcribed prescription/order with date, time, name, and title. 

      • For either CPOE or CDC 7221, the individual transcribing the telephone/verbal prescription/order shall be indicated.

      • Telephone/verbal prescriptions/orders shall be signed or electronically authorized via CPOE by the provider or another primary care provider (advanced practice provider, dentist, physician, or psychiatrist) as designated by the prescriber or Chief Medical Executive (CME)/Chief or Senior Psychiatrist/Supervising Dentist, or designee, within 48 hours or no later than the next business day following a weekend or holiday.

    • Telephone/Verbal Prescriptions/Orders for DEA CIII-V Controlled Substances

      • For telephone/verbal prescriptions/orders given to licensed nursing staff, the provider who initiated the prescription/order is required to sign the prescription/order in the DEA-certified electronic prescription application or make telephone contact with the pharmacist for generating the DEA-compliant verbal prescription/order.

      • Telephone/verbal prescriptions/orders for DEA CIII-V controlled substances shall be signed prior to a dispense from pharmacy, or within 48 hours or no later than the next business day following a weekend or holiday for medications administered from an automated drug dispensing system (ADDS).

    • Duration of Prescriptions/Orders for Outpatients

      • Duration for medication prescriptions/orders shall be specified in days, doses, hours, minutes, or weeks. 

      • Mental health medications, which only include those with a mental health indication written by a psychiatrist, or a psychiatric nurse practitioner (working under the supervision of a psychiatrist), may be prescribed/ordered for a maximum duration of 180 days.  The Mental Health Services Delivery System Program Guide requirements for minimum frequency of patient appointments are not impacted by this procedure. 

      • Maximum duration for prescriptions/orders for DEA CII-V controlled substances shall comply with the HCDOM, Section 3.5.9, DEA Schedule II-V Controlled Substances, Section (d)(4)(B), Duration of Controlled Substances Orders.

      • All other medications may be prescribed/ordered for a maximum of 360 days, except where otherwise restricted by the formulary, regulation, or policy.  When clinically appropriate, the duration of prescription orders shall be written in increments of 30 days and shall not exceed 360 days.

    • Scheduling of Non-Daily Medications

      • Medications prescribed/ordered twice weekly (e.g., isoniazid and vitamin B6) shall preferably occur on Tuesdays and Fridays unless otherwise specified by the prescriber.  

      • Excluding one-time doses and vaccines, medications prescribed/ordered weekly, every two weeks, three weeks or four weeks (e.g., long-acting depot mental health injections) shall preferably occur on Tuesdays unless otherwise specified by the prescriber.

      • The scheduled days of administration shall be included in the directions for administration on the Medication Administration Record (MAR) either via CPOE or by pharmacy entry.

    • Mandatory Crush/Open Medications List

      • The Systemwide P&T Committee mandates that certain medications be administered “Crush/Open and Float” as appropriate per the formulation.

      • Medications on the Systemwide P&T Committee’s Mandatory Crush/Open Medications List shall include the words “Crush/Open and Float” in the directions on the label for inclusion in the medication profile and MAR.

        • This labeling shall be automatically applied to all eligible medications regardless of whether the provider’s prescription/order included “Crush/Open and Float” directions.

        • Any prescription/order from a provider to request an exception from “Crush/Open and Float” administration for an eligible medication requires approval from the institution’s CME, or designee, or Chief/Senior Psychiatrist or designee.

    • Monitoring and Prescription/Order Related Problems

      • A pharmacist shall be responsible for screening all prescriptions/orders for potential problems including, but not limited to, drug-drug interactions, drug-food interactions, drug-condition interactions, contraindications, allergies, unclear rationale of therapy or polypharmacy, duplicate therapy, and legibility (where applicable). 

      • A pharmacist, as part of the interdisciplinary patient care team, shall be involved in the ongoing assessment of a patient’s drug therapy within the legal limits of their scope of practice.

      • Organization-approved point-of-care immunizations and protocols as well as prescriber-ordered medications for emergent care where in the prescriber’s professional judgment, a delay in therapy may cause patient harm, a medication may be removed from an ADDS or from licensed correctional clinic (LCC) stock and administered to a patient prior to screening by a pharmacist. Any removal of medication from an ADDS or LCC stock shall be documented and provided to the correctional pharmacy for review. 

      • A pharmacist shall contact the prescriber directly for clarification.  If the prescriber cannot be reached, pharmacy staff shall follow EHRS Clinical Leadership Advisory Committee Approved Workflows, Workflow 700-210, Pharmacy, Incomplete Clarification Workflow. 

      • Prescription/order changes, clarification, or cancellations shall be received from the provider via CPOE or through a telephone or written prescription/order.

      • Problems shall be resolved ensuring that applicable turnaround times are met.

    • Discontinued, Suspended, or Hold Prescriptions/Orders

      • An order shall be obtained from a provider before any prescribed medication is withheld from a patient, unless administration is clinically contraindicated.  Blanket orders to withhold medications from groups of patients are not permissible.

      • When a KOP medication is to be discontinued due to clinical reasons (e.g., drug-drug interaction, pending surgery), the primary care or mental health team shall notify the patient.

      • Within EHRS, when a medication is to be held, the provider shall discontinue the current prescription/order and generate a new prescription/order with a start date/time for the intended resumption.  When a “hold” prescription/order is written on a CDC 7221, it shall be interpreted to mean “discontinue.”  If the specific time or date to resume medications is not clear on the CDC 7221, the pharmacy shall immediately contact the prescriber for clarification.  If the provider is unavailable, clarification shall be sought via the process outlined in EHRS Clinical Leadership Advisory Committee Approved Workflows, Workflow 700-210, Pharmacy, Incomplete and Clarification Workflow.

    • Product Substitutions

      • Generic equivalent medications shall be automatically substituted by the correctional pharmacy in place of brand name medications if available. 

      • Specific requests for the use of a brand name medication shall be regarded as formulary exceptions and shall follow the nonformulary approval process with strong clinical justification for why a generic or an alternative generic medication is inappropriate. 

      • The correctional pharmacy shall substitute alternate strengths of the generic equivalent medication to equal the dose prescribed as necessary to maintain continuity of care.

      • For medications which are available in different formulations or salts, when the Systemwide P&T Committee deems these medications to be clinically equivalent, therapeutic substitution may be performed by the pharmacist in accordance with the HCDOM, Section 3.5.6, Therapeutic Interchange and Automatic Substitution.

    • Medication Availability

      • Most formulary NA or DOT medications shall be readily available through the licensed correctional clinic (LCC) or automated drug delivery system (ADDS) supplies for administration following a pharmacist’s authorization.

      • During business hours, if the medication is unavailable through the LCC, pharmacy staff shall provide the ordered medications.

        • Non-urgent new medication orders received by pharmacy on any business day shall be available to the patient no later than three business days unless otherwise ordered (e.g., order specifies medication to start today).

        • Non-urgent renewed medication orders received by pharmacy on any business day shall be available to the patient prior to exhaustion of previous medication supply unless otherwise ordered (e.g., order specifies medication to start today).

      • If the correctional pharmacy is closed, licensed health care staff shall contact the after-hours Central Pharmacy Services to authorize the order.  Licensed nursing staff shall then obtain the ordered medication from the LCC or ADDS.  This medication shall be administered NA or DOT (or may be KOP if available for a Registered Nurse (RN) to dispense) and shall be documented on the MAR.

      • Medications for New Arrivals

        • Patients arriving in the institution from a site other than a CDCR institution who are on prescription medications shall be seen by a health care provider or have their prescription medications ordered within eight hours of arrival to prevent any interruption in medication delivery.  The medication shall be administered at the next dosing time and no later than the next calendar day.

        • Patients arriving from CDCR institutions shall be provided medications for which they have active orders; orders that are at or near expiration shall be renewed by a health care provider within eight hours of arrival, as indicated.

      • Start Time of Medication Orders

        • Medications may not be ordered “STAT” in the outpatient clinic setting in CDCR. STAT orders are appropriate only in the Triage and Treatment Area, urgent/emergent treatment areas, or Licensed Inpatient areas. 

        • If a medication should be started on the same day, the provider shall adjust the start date and time during order entry and may need to verbally notify the medication administration staff of the same-day order.

        • If any STAT/same-day order medication is unavailable, the prescriber or on-call provider shall immediately be notified for treatment recommendations.

      • Medications Not Available

        • Patient Out of Medication – When licensed nursing staff become aware that a patient with a valid routine medication order has run out of their medication supply (KOP, NA, or DOT), licensed nursing staff shall make every effort to promptly obtain the medication as appropriate.

        • In situations where medications are not available locally, the prescriber or on-call provider shall be contacted for appropriate orders depending on clinical need until the pharmacy can procure the required medications per routine process.

    • Medication Refills

      • Medications may be refilled automatically in the pharmacy dispensing database in accordance with policy.  Providers should consider discontinuing auto-refill for those patients who repeatedly miss doses despite appropriate patient counseling. 

      • CDCR 7362, Health Care Services Request Form, Refill Request

        • KOP medications that are not included in the auto-refill process shall include the words “Request Refill” on the medication label.  Patients must request refills of these medications using the CDCR 7362 or other approved processes.

        • The completed CDCR 7362 shall be submitted pursuant to the established CDCR 7362 process.  Licensed nursing staff shall process refill requests according to Local Operating Procedures (LOP).

      • NA or DOT medications that are not included in the auto-refill process shall include the words “Request Refill” on the medication label.  Licensed nursing staff shall process refill requests for these medications according to the LOP.

    • Medication Renewals

      • Patients may request medication renewals by submitting a CDCR 7362 indicating their medication needs. 

      • The prescriber is responsible for renewing medication orders with appropriately timed follow-up visits to facilitate medication continuity. 

      • Licensed nursing staff shall request a new order from a prescriber when it is determined that an order for a medication for an ongoing health condition has expired.

      • Patients shall be scheduled to be seen by the prescriber prior to expiration of their medication when required by institution policy or when indicated.

  • References

    • Code of Federal Regulations, Title 21, Chapter I, Subchapter C, Part 290, Subpart A, Section 290.10, Definition of Emergency Situation

    • Code of Federal Regulations, Title 21, Chapter II, Part 1301, Subpart, Section 1301.13, Application for registration; time for application; expiration date; registration for independent activities; application forms, fees, contents and signature; coincident activities

    • California Business and Professions Code, Division 2, Chapter 9, Article 2, Section 4016

    • California Business and Professions Code, Division 2, Chapter 9, Article 2, Section 4019

    • California Business and Professions Code, Division 2, Chapter 9, Article 2, Section 4024

    • California Business and Professions Code, Division 2, Chapter 9, Article 2, Section 4040

    • California Business and Professions Code, Division 2, Chapter 9, Article 4, Section 4070

    • California Business and Professions Code, Division 2, Chapter 9, Article 7, Section 4126.5, Furnishing Dangerous Drugs by Pharmacy

    • California Business and Professions Code, Division 2, Chapter 9, Article 7.5, Compounded Sterile Drug Products

    • California Business and Professions Code, Division 2, Chapter 9, Article 7.6, Section 4128.5, Labeling for Unit-Dose Medications

    • California Business and Professions Code, Division 2, Chapter 9, Article 7.7, Outsourcing Facilities

    • California Business and Professions Code, Division 2, Chapter 9, Article 13.5, Sections 4187-4187.5

    • California Health and Safety Code, Division 10, Chapter 4, Chapter 4, Section 11150

    • California Health and Safety Code, Division 10, Chapter 4, Article 1, Section 11162.1

    • California Code of Regulations, Title 15, Division 3, Chapter 2, Subchapter 3, Section 3999.381, Rescue Medications

    • California Department of Corrections and Rehabilitation Department Operations Manual, Article 43, Section 54030.1, Policy

    • California Correctional Health Care Services Formulary

    • Health Care Department Operations Manual, Chapter 1, Article 4, Section 1.4.2.2, Advanced Practice Provider

    • Health Care Department Operations Manual, Chapter 2, Article 1, Section 2.1.2, Effective Communication Documentation

    • Health Care Department Operations Manual, Chapter 2, Article 1, Section 2.1.3 Over-the-Counter Products

    • Health Care Department Operations Manual, Chapter 3, Article 5, section 3.5.3 Furnishing or Dispensing Medication to Legally Authorized Persons or Entities: Licensed Correctional Clinics

    • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.4, Automated Drug Delivery System

    • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.5, CCHCS Drug Formulary

    • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.6, Therapeutic Interchange and Automatic Substitution

    • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.9, DEA Schedule II-V Controlled Substances

    • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.14, Additional Requirements Pertaining to Licensed Inpatient Facilities

    • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.16, Medication Inventory Management, Labeling, and Storage

    • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.29, Medication Administration

    • California Department of Corrections and Rehabilitation, Mental Health Services Delivery System Program Guide

  • Revision History

  • Effective: 03/2008
    Revised: 11/18/2025