Policies and procedures

Running the pharmacy

1. Who is in charge

The licensee, the pharmacist in charge, supervision whenever the pharmacy is open, and what must be reported to the VPA.

Version 4 · approved 27 September 2026 by Sam Nguyen

The licensee's responsibility

The licensee is responsible for how the pharmacy is run, whether or not they are on site.
They should keep an active, ongoing interest in how the pharmacy is being conducted — through visits and staff meetings often enough to know — and step in to address any imminent safety risk, or anything not being done properly.
They make sure everyone who provides a service here, pharmacist or not, is suitably qualified and legally able to provide it.
These responsibilities cannot be handed to a co-owner or an employee, including the pharmacist in charge.
To reach the licensee about something urgent: 0413 662 907.

Regulator guidance · PBA Guidelines on the safe provision of pharmacy services s1 (Note for proprietor pharmacists) · VPA Guidelines G1.2.5 · VPA Standard 1.1.1

The pharmacist regularly and usually in charge

Our PRUIC is Marisa Toldo.
The VPA is notified of the appointment, and of any change (form VP32).

Legal requirement · VPA Standard 1.2.1(a)–(c) · VPA Circular 26

What being PRUIC means

A pharmacist can be PRUIC of only one pharmacy at a time.
The PRUIC should work a majority of the pharmacy's standard hours, on a regular, ongoing basis.

Regulator guidance · VPA Guidelines G1.2.1

When the PRUIC is away

If the PRUIC will be away for more than 28 days, Daniel Okonkwo — 0412 884 301 should be appointed PRUIC for that time and the VPA should be told (form VP32).
For shorter absences, a registered pharmacist should always be on duty and in charge — Daniel Okonkwo — 0412 884 301 is who to call first.

Regulator guidance · VPA Circular 26

Recording who's covering

Where we record who's covering: The dispensary daybook, front page.
That way every shift can check who's in charge without guessing.

Pharmacy's own choice · VPA self-audit 1.2.4

A pharmacist present whenever open

The pharmacy is personally supervised by a registered pharmacist, physically present, at all times it is open.
If no pharmacist is present, the pharmacy does not open, or it closes. Staff do not trade "until the pharmacist arrives".
The pharmacist oversees the area where pharmacy services are provided.

Legal requirement · Pharmacy Regulation Act s 30 · VPA self-audit 1.1.2 · VPA Standards FAQ Q10

When the pharmacy is closed

No one enters the pharmacy while it is closed unless a registered pharmacist is present. That includes staff, cleaners and contractors.

Legal requirement · Pharmacy Regulation Act s 31 · VPA Circular 26 · VPA self-audit 1.1.2

Names on display

The licensee's name as shown on the VPA public register — and, for a company, its directors' names — should be displayed at every public entrance, visible from the street or walkway.
The PRUIC's name should be displayed as PRUIC in the professional service area or where medicines are collected — Marisa Toldo — and the sign should change the same day the PRUIC changes.
Every pharmacist on duty should be identifiable by name, matching their registered name — a name badge is enough.
Customers should be able to easily tell who is staff and what each person's role is (for example, from their badge).

Regulator guidance · VPA Guidelines G1.2.1.1 · VPA self-audit 1.1.1 · 1.2.1 and 1.2.4

What we tell the VPA, and when

- If the licensee is a company, a change of director, shareholder or office holder: within 14 days.
- A change to the pharmacy's registered business name: within 14 days.
- A change of PRUIC: notified to the VPA (form VP32).
- A change to a commercial arrangement affecting the business: told to the VPA before it takes effect (form VP31).
- Closing the business: at least 14 days before (form VP34).

Legal requirement · Pharmacy Regulation Act ss 25 and 27 · VPA Guidelines (Introduction) · VPA Standard 1.2.1 · VPA Circular 26 · VPA self-audit 1.1.1 · VPA ownership guidance

Any other business at the premises

No other person or business carries on any business or activity at the pharmacy unless the VPA has approved it or the licence permits it.
If in doubt, ask the VPA before agreeing to anything.
Approval is sought on VPA form VP43. An approval belongs to the licence: if the pharmacy changes hands, the new licensee must apply again.

Legal requirement · Pharmacy Regulation Act s 24 · VPA Circular 30

Running the pharmacy

2. Policies, quality and risk

How this manual is kept current and used, the self-audit, quality improvement, risk management and insurance.

Version 1 · approved 23 September 2026 by Sam Nguyen

This manual

This manual covers how the pharmacy operates, how it is governed and every service it provides.

Legal requirement · VPA Standard 1.4.1 · VPA Guidelines G1.4.1

Approving the manual

It should be approved by the licensee, or someone they delegate, before it is used.
Each policy shows when it was approved and by whom.

Regulator guidance · VPA Guidelines G1.4.2

Keeping it current

Each policy should be reviewed at least every two years, and sooner after a change in how a service is delivered, an incident, a complaint or a near miss, or a change in the law or the standards.
Only the current version should be in use. Earlier versions are kept, clearly marked as superseded, for reference.

Regulator guidance · VPA Standard 1.4.2 · VPA Guidelines G1.4.2

Knowing and following the procedures

Every staff member should know where to find the current procedures for their role and be able to read them at any time.
New staff should be taken through the relevant procedures at induction, and this should be recorded.
The licensee should make sure that compliance with procedures is watched and recorded, and that lapses are dealt with promptly. Day-to-day, the pharmacist in charge does this for them.

Regulator guidance · VPA Standard 1.4.3 · VPA Guidelines G1.4.3

The VPA self-audit

The pharmacy should complete the VPA self-audit twice a year while services are new, and for high-risk areas, and at least once a year once they are established.
The licensee should review every finding, and each problem should become an action with a person responsible and a due date.

Regulator guidance · VPA self-audit form (Introduction)

Improving the service

Feedback, incidents, audits and spot checks should be used to find ways to make services safer and better.
Each improvement should be documented — what was found, what will change, who will do it, by when, and whether it worked.

Regulator guidance · VPA Standard 1.5.1 · VPA Guidelines G1.5.1 · VPA self-audit 1.5.1

Risk management

A risk register should list the main risks for each service the pharmacy provides — professional, legal, financial and reputational — and what is done to reduce each one.
It should be reviewed regularly — here, at least once a year and after any serious incident — and staff should be told about the risks relevant to their work.
Where ours is kept: not yet recorded.

Regulator guidance · VPA Standard 1.5.3 · VPA Guidelines G1.5.3 · VPA self-audit 1.5.3

Business continuity

There should be a plan for keeping patients safe and staying within the law if something disrupts the pharmacy — a power or IT outage, a flood or fire, or the loss of key staff — including an emergency procedure.
Where it's kept, alongside the risk register: not yet recorded.

Regulator guidance · VPA Guidelines G1.5.3

Insurance

The pharmacy should hold public liability and other appropriate business insurance.
Every pharmacist working here should be covered by professional indemnity insurance that meets the Board's standard — their own, or the pharmacy's.

Regulator guidance · VPA Guidelines G1.5.3 · PBA Guidelines on the safe provision of pharmacy services s1 (from 1 Oct 2026)

Running the pharmacy

3. Incidents, near misses and complaints

What to do when something goes wrong or nearly does, how it's recorded and investigated, and how concerns are raised.

Version 1 · approved 23 September 2026 by Sam Nguyen

What to report

Plain-English meanings (the VPA does not define these terms):
- **Incident**: something went wrong — for example, the wrong medicine or strength was supplied.
- **Adverse event**: a patient was harmed while receiving a pharmacy service.
- **Near miss**: something would have gone wrong but was caught in time — for example, a wrong medicine picked but noticed before it reached the patient.
Every incident, adverse event and near miss should be recorded. Near misses are how problems get found before they cause harm.

Regulator guidance · VPA Standard 1.5.2 · VPA Guidelines G1.5.2

When something goes wrong

1. Work out how serious it is. Can it be resolved here, or does the patient need medical attention?
2. Act straight away to prevent further harm — for example, get the correct medicine to the patient.
3. Record it as soon as possible, preferably by the pharmacist involved: what happened, who was affected, where and how.
4. Be open with the patient, or their family or carer, about what happened.
5. Tell the pharmacist in charge and the licensee (0413 662 907).
6. Investigate: what happened, how, why, and what will stop it happening again.

Regulator guidance · VPA Guidelines G1.5.2

How deep the investigation goes

- Minor incidents and near misses: recorded and looked into locally.
- Moderate incidents where a patient was harmed: usually an in-depth case review, led by a senior person such as the licensee or pharmacist in charge.
- Serious incidents with significant harm: a root cause analysis, started as soon as possible.

Regulator guidance · VPA Guidelines G1.5.2

The incident register

Every incident, adverse event and near miss should go into one dedicated incident register. We record complaints there too.
Where it's kept: not yet recorded.
Each record should show when it happened, who was involved, what happened, contributing factors, what the investigation found, the actions taken and follow-up, and who recorded it.

Regulator guidance · VPA Guidelines G1.5.2 and Appendix 5 · VPA self-audit 1.5.2

Looking for patterns

Incidents should be reviewed regularly for trends and shared causes.
Anything found should become an improvement action, recorded with who will do it and by when, and followed up.

Regulator guidance · VPA Guidelines G1.5.1 and G1.5.2

Complaints

Listen, apologise where appropriate, and try to resolve it on the spot.
Record every complaint in the incident register with what was done. The pharmacist in charge follows up any that aren't resolved.

Pharmacy's own choice · VPA Guidelines G1.5.1

Raising a concern

Anyone can raise a concern about safety, practice or how the pharmacy is run — with the pharmacist in charge or directly with the licensee.
We want people to speak up. Raising a concern in good faith is welcomed, not punished.

Regulator guidance · VPA self-audit 1.2.3 and 1.5.1

Passing information between shifts

Anything the next pharmacist needs to know — owings, follow-ups, a patient to call back, a fault — is written in the handover log before the end of the shift, and read at the start of the next.

Pharmacy's own choice · VPA self-audit 1.5.2

Running the pharmacy

4. Privacy and patient records

Keeping patient information secure, private conversations, keeping what people buy private, cyber security, and disposing of records.

Version 1 · approved 23 September 2026 by Sam Nguyen

Why this matters

Patient health information is protected by the Privacy Act 1988 and Victoria's Health Records Act 2001.
It is used and shared only to care for the patient and run the pharmacy, in ways the patient would expect, with their consent, or where the law requires or allows it — for example PBS claims, SafeScript, or a serious threat to someone's safety.

Legal requirement · Privacy Act 1988 (APPs) · Health Records Act 2001 (Vic) · Schedule cl 9(c) · OAIC Guide to Health Privacy ch 3

A patient asking to see or correct their information

A patient who asks to see or correct their information is referred to the pharmacist in charge, who responds within 30 days.

Pharmacy's own choice · OAIC Guide to Health Privacy ch 4 · Health Records Act 2001 (Vic)

Where patient records are kept

Paper patient records should be kept in the dispensary or in a locked facility.
Electronic records should be held securely on site or with a secure cloud provider.
Ours: not yet recorded.

Regulator guidance · VPA Guidelines G1.3.1 · VPA self-audit 1.3.2

Not giving information away by accident

Medicine details should be given only to the person they belong to, unless that person agrees otherwise.
Take care that family members paying an account, anyone paying for someone else, and account-processing or statistics companies don't learn what medicines a person takes by accident. This doesn't stop disclosures the law requires, such as PBS claims.

Regulator guidance · VPA Guidelines G1.3.2 and G2.4.10

Private conversations

Prescriptions are handed in, and counselling happens, at a private counselling point where others can't overhear.
Staff use these points routinely for all prescription transactions.
Where a longer or more sensitive conversation is needed, use the consultation room if there is one.

Legal requirement · Schedule cl 9(g) · VPA Guidelines G2.4.6 and G2.4.7

Keeping medicines private at the counter

No one else in the pharmacy should be able to tell what medicine a customer is buying or collecting.
Dispensed medicines go to the checkout covered or bagged, never in open baskets.
Scripts waiting for collection are stored so no one can link them to the person.

Legal requirement · Schedule cl 9(h) · VPA Guidelines G2.4.10

At the checkout

Checkout staff don't read out or discuss the medicine.

Pharmacy's own choice · VPA Guidelines G2.4.10

Staff confidentiality

Every staff member should be told that everything they learn about customers is confidential.

Regulator guidance · VPA Guidelines G2.4.10

Cyber security

- Everyone should have their own login with a strong password, and logins should never be shared.
- Multi-factor authentication should be on for the daily login and every system holding patient information.
- Software and operating systems should update automatically on every device.
- Data should be backed up regularly to an encrypted, separate device or secure cloud, and a restore tested regularly (we do it quarterly).
- Anti-virus and firewall software should be current.
- Wi-Fi should be password-protected, the default password changed, and the network kept away from public use.
- No personal or non-work apps should be installed on work devices.
- Staff should be trained to spot phishing emails and texts.

Regulator guidance · VPA Guidelines G1.3.2.1 · VPA self-audit 1.3.2

If there is a cyber incident

If a device, account or system may have been compromised: disconnect it from the network, tell the pharmacist in charge and the licensee straight away, and log it as an incident. Follow the pharmacy's cyber incident procedure and fill in the incident report form.

Pharmacy's own choice · VPA Guidelines G1.3.2.1

Deciding whether to notify

The licensee assesses within 30 days whether it is a notifiable data breach. If it is, the licensee notifies the OAIC and affected patients as soon as practicable.
Any breach involving My Health Record is reported to the Australian Digital Health Agency.

Legal requirement · Privacy Act 1988 Part IIIC · OAIC Notifiable Data Breaches scheme · My Health Records Act 2012 (Cth)

Disposing of records

Records no longer needed — and only once any legal retention period has passed — are destroyed securely.
Paper with patient details is shredded or placed in a locked secure-destruction bin, never in general waste.
Old devices are wiped or destroyed before disposal.

Pharmacy's own choice · VPA self-audit 1.3.2

Medicines

5. Schedule 8 medicines

Storing, recording, checking and destroying Schedule 8 (and any Schedule 9) poisons, and what to do when the count doesn't match.

Version 2 · approved 23 September 2026 by Sam Nguyen

What this covers

All Schedule 8 poisons (drugs of dependence) held at the pharmacy — stock, patient returns, and expired stock awaiting destruction — and any Schedule 9 poison held lawfully.
Only pharmacists keep the register and hold the safe key or code. S8 deliveries go straight to a pharmacist.

Legal requirement · VPA Standard 1.1.3 · VPA Standard 1.3.3 · DPCS Regulations 2017 · VPA Guidelines G1.1.3

Where S8 is kept

All S8 stock is kept in the S8 safe. Nothing else goes in it except other drugs of dependence.
The safe is fixed to the floor or wall and gives no less security than a 10 mm mild steel drug cabinet.
It is big enough to hold everything on hand — including returns and expired stock awaiting destruction — and laid out so the right product can be picked accurately.

Legal requirement · DPCS Regulations 2017 r 74 (per DH guide) · VPA Standard 2.4.2(f) · VPA Guidelines G1.1.3 and G2.4.2

Keys and codes

Only pharmacists hold the S8 safe key or code.
During trading, the pharmacist on duty keeps the key on their person, or locked in a key safe of equal security that only pharmacists can open.
The key is never left in the door or in a "hidden" spot another person could find.
The key is not left on the premises overnight unless it is locked in a separate safe of at least equal security, which only pharmacists can open.

Legal requirement · DPCS Regulations 2017 r 74 (per DH guide) · VPA Guidelines G2.4.2 · VPA self-audit 1.1.3

Receiving S8 stock

S8 deliveries should be handed straight to a pharmacist, not left with other stock.
The pharmacist should put them in the safe and record the receipt in the register as soon as practicable.

Regulator guidance · VPA Guidelines G1.1.3

Recording in the register

Which S8 register we use, and where it's kept: not yet recorded.
Every S8 transaction — receipt, supply, return, destruction — is recorded in the register as soon as practicable after it happens, by the pharmacist involved.
Each entry shows the balance left after the transaction.
That balance comes from counting the stock on hand, not from subtracting on paper.
One way to show a balance was counted is to tick it or add a separate line.

Legal requirement · DPCS Regulations 2017 r 108 (per DH guide) · VPA Guidelines G1.3.3

Full reconciliation

How often the whole register is reconciled: weekly.
A pharmacist checks every S8 line against the recorded balance, orders received and prescriptions supplied, then records the result — including the number of discrepancies found, even when it is zero.

Pharmacy's own choice · VPA Guidelines G1.3.3

When the count doesn't match

Act without delay.
1. Record the true balance you counted.
2. Mark the discrepancy clearly in the register.
3. Investigate it: recheck the count, orders, prescriptions and earlier entries.
4. If you resolve it, record the explanation in the register.
5. If you can't resolve it, notify the Department of Health, Medicines and Poisons Regulation, without delay (dpcs@health.vic.gov.au, 1300 364 545). Also tell the licensee.
6. Log it as an incident.

Legal requirement · DPCS Regulations 2017 r 112 (per DH pharmacists page) · VPA Guidelines G1.3.3 · VPA self-audit 1.3.3

Returned and expired S8

S8 returned by patients, and S8 stock that has expired or is unwanted, stays in the S8 safe until destroyed.
It is recorded in the register when it comes in.

Legal requirement · VPA Guidelines G2.4.2 · VPA self-audit 1.3.3

Destroying S8

A pharmacist destroys S8 in front of a witness who is a pharmacist, medical practitioner, dentist, veterinary practitioner, nurse or midwife.
Before it goes into a returned-medicines (RUM) bin, it is made unidentifiable and unrecoverable.
The register records the date, drug and strength, quantity, reason, and the names of the pharmacist and the witness.

Legal requirement · DPCS Regulations 2017 r 115 (per DH guide) · DH guide Managing Schedule 8 poisons

Keeping the register

S8 registers and records are kept for at least 3 years.

Legal requirement · DPCS Regulations 2017 r 108 (per DH guide)

Pharmacotherapy stock in use

Bulk methadone and buprenorphine in use for dosing should be kept where patients cannot reach it and, where possible, cannot see it.
The total quantity used each day should be recorded in the register.

Regulator guidance · VPA Guidelines G1.3.3 and G2.4.2

Medicines

6. Pharmacy, Pharmacist Only and prescription medicines

Where S2, S3 and S4 medicines are kept, how they are supplied, returned medicines, and medicines that can be misused.

Version 1 · approved 23 September 2026 by Sam Nguyen

Where scheduled medicines are kept

All scheduled medicines are stored and displayed as the Drugs and Poisons legislation requires.
Prescription-only (S4) medicines are kept in the dispensary, or in a locked facility, where a pharmacist can supervise them — including in storerooms, packing and dispatch areas and fridges.
Take particular care when S4 deliveries arrive.

Legal requirement · VPA Standard 1.1.3 · VPA Guidelines G1.1.3 · DPCS Regulations 2017

Pharmacist Only (S3) medicines

S3 medicines are stored so customers cannot help themselves, and are not displayed or promoted in a way that draws attention to them.
Before any S3 supply, the pharmacist personally satisfies themselves that there is a therapeutic need.
The pharmacist supplies it, or directly supervises the supply, and gives directions for use.
One pack is supplied at a time, unless the circumstances are exceptional — and then the reason is recorded.

Legal requirement · VPA self-audit 1.1.3 · DPCS Regulations 2017 (regulation number unverified)

Pseudoephedrine

All stock containing pseudoephedrine should be kept out of public view.
Stock held for sale should be no more than one week's sales.

Regulator guidance · VPA Guidelines G1.1.3 · VPA self-audit 1.1.3

Pharmacy Medicines (S2)

Non-pharmacist staff may sell Pharmacy Medicines. The pharmacist on duty should routinely monitor those sales.

Regulator guidance · VPA self-audit 1.1.3

When staff should ask a pharmacist

Staff refer to the pharmacist whenever they are unsure, and always for a request that seems unusual, repeated or excessive.

Pharmacy's own choice · VPA self-audit 1.1.3

Medicines that can be misused

Sales of medicines known to be abused or misused are supervised and monitored by the pharmacist.
The licensee decides what goods the pharmacy stocks, paying particular attention to these medicines.

Legal requirement · Schedule cl 9(d) · VPA self-audit 1.1.3 · VPA Guidelines G1.2.5

Staff and these medicines

Staff refer every request for these medicines to the pharmacist.

Pharmacy's own choice · VPA Guidelines G1.2.5

The professional service area

The professional service area should be a distinct area with a "Professional Service Area" sign.
It should display and store only products for therapeutic use and information about them.

Regulator guidance · VPA Guidelines G2.4.5

Medicines are never re-used

Once a medicine has been dispensed and has left the pharmacy, it is never put back into stock or supplied again — whatever its condition.
Anything returned goes for disposal.

Legal requirement · Schedule cl 9(b)

Returned and unwanted medicines

Returned medicines, including those from aged care homes and returned dose administration aids, and expired or unwanted stock should be stored securely until disposal.
They should be disposed of regularly through a specialist waste service such as the returned unwanted medicines (RUM) program.
Returned or expired Schedule 8 medicines follow the Schedule 8 policy instead.

Regulator guidance · VPA Guidelines G1.1.3 · VPA self-audit 1.1.3

Medicines

7. Cold chain and medicine fridges

Keeping refrigerated medicines between 2 and 8°C, checking the fridges, and what to do when something goes wrong.

Version 1 · approved 23 September 2026 by Sam Nguyen

What this covers

Every medicine that must be kept refrigerated, including vaccines, and every fridge used to store them.
Refrigerated medicines should be kept between 2°C and 8°C, aiming for 5°C.

Regulator guidance · VPA Standard 2.4.2(b) · VPA Guidelines G2.4.3 · Strive for 5 (4th ed)

Which fridges we use

Medicine fridges should hold medicines only — no food, drink, specimens or anything else.
Vaccines should be kept in a purpose-built vaccine refrigerator. Domestic, bar or general commercial fridges should never be used for vaccines.
A vaccine fridge outside the dispensary should be kept locked when not in use.
Fridges should sit out of direct sunlight with air space around them as the manufacturer specifies, and vaccine fridges should be serviced every 12 months.

Regulator guidance · VPA Standard 2.4.2(b) · VPA Guidelines G2.4.3 · Strive for 5 (4th ed)

Continuous temperature logging

Every medicine fridge should have a data logger recording at least every 5 minutes, connected so it alerts staff to a fault when the pharmacy is closed.
The logger data should be downloaded and reviewed at least once a week, and any excursion investigated.

Regulator guidance · VPA Guidelines G2.4.3 · VPA self-audit 2.5.1.3 · Strive for 5 (4th ed)

Twice-daily temperature check

Twice each trading day — at opening and at close — each fridge's minimum, maximum and current temperature should be recorded.
The thermometer or logger display should be reset after each reading.
The actual numbers should be recorded. A tick is not a record.
Any reading outside 2–8°C is handled under "When the temperature goes out of range".

Regulator guidance · VPA Guidelines G2.4.11 (note) · Strive for 5 (4th ed)

What counts as out of range

Any temperature below 2°C or above 8°C is a cold chain breach.
The only exception is a single brief rise to no more than 12°C lasting less than 15 minutes, for example while restocking.
If you are not sure, treat it as a breach.

Regulator guidance · Strive for 5 (4th ed) · Victorian cold chain management protocols

When the temperature goes out of range

1. Do not use or supply anything from the affected fridge.
2. Keep the stock refrigerated between 2°C and 8°C — if the fridge itself has failed, move it to the backup fridge. Backup fridge: not yet recorded.
3. Label the stock "Do not use — do not discard". Do not throw anything away.
4. Tell the pharmacist in charge straight away.
5. Record the minimum and maximum temperatures reached and how long the excursion lasted, using the logger data.
6. Government-funded vaccines: report the breach to the Victorian Department of Health as soon as possible, by emailing the cold chain breach report form and logger data to immunisation@health.vic.gov.au. Follow their advice before using or discarding anything.
7. Privately bought vaccines: contact the manufacturer for advice.
8. Other medicines: the pharmacist assesses each product against its product information or the manufacturer's advice before any of it is supplied.
9. Log it as an incident, including what caused it and what was done to stop it happening again.

Regulator guidance · Strive for 5 (4th ed) · Victorian cold chain management protocols · VPA Guidelines G1.5.2

Receiving refrigerated stock

Refrigerated lines should be put into a medicine fridge as soon as the delivery arrives, in their original packaging.
Any temperature indicator in the delivery should be checked. If it shows the stock has been out of range, or you can't tell, keep the stock refrigerated, label it "Do not use — do not discard", and tell the pharmacist.

Regulator guidance · VPA Guidelines G2.4.3 · Strive for 5 (4th ed)

Power failure

Keep the fridge door closed and keep watching the temperature.
If the temperature approaches 8°C, move the stock to alternative cold storage that holds 2–8°C and keep monitoring it.
Record the times and temperatures. If anything went outside 2–8°C, follow "When the temperature goes out of range".

Regulator guidance · Strive for 5 (4th ed)

Supplying refrigerated medicines

The patient or their agent should be told that the medicine needs to be refrigerated, and the label should say so.

Regulator guidance · VPA Guidelines G2.4.3

Room temperature storage

All areas where medicines are stored should be kept at or below 25°C by thermostatically controlled air conditioning, including overnight and when the pharmacy is closed.

Regulator guidance · VPA Standard 2.4.3 · VPA Guidelines G2.4.3

Keeping the records

Temperature records, logger downloads, breach reports and fridge service records are kept for 5 years.

Pharmacy's own choice · VPA Guidelines G2.5.5

Services

8. Dispensing and prescription records

Who may dispense, what the prescription record must contain, signing and keeping records, references, and using the dispensary.

Version 2 · approved 27 September 2026 by Sam Nguyen

Who dispenses

Medicines are supplied, compounded or dispensed only by a pharmacist, or by trained staff working under a pharmacist's direct supervision.
A pharmacist who delegates a task stays professionally responsible for it. The pharmacist does the final check before the medicine is supplied.

Legal requirement · Pharmacy Regulation Act s 29(2) · Schedule cl 8 · VPA Standard 1.2.3 · VPA self-audit 1.2.5

Dispensing safely

The pharmacist takes reasonable steps to make sure that dispensing a prescription is safe for the person who will take it.
Medicines are dispensed as ordered, as far as that is safe for the patient. If it isn't, the pharmacist contacts the prescriber to check or change the order.

Legal requirement · Pharmacy Regulation Act s 32(1) · Schedule cl 9(a) · DH Victoria — Legislative requirements for pharmacists

What the prescription record contains

Every prescription dispensed is recorded in English, including:
- the patient's name and address
- the date dispensed
- the medicine's name, dose form and strength (or formula)
- the quantity or number of doses ordered
- the directions, and any other instructions on the label
- the prescriber's name, address and phone number
- any change made to the original prescription
- any other information about the medicine and its use

Legal requirement · Pharmacy Regulation Act s 32(2)–(3) · Schedule cl 10

Making and signing the record

The record is made at the time of dispensing — or, in an emergency, within 24 hours.
Within 24 hours the dispensing pharmacist certifies with their handwritten signature that they dispensed it: in the record itself or, where the system doesn't allow that, in a separate signed record kept with the prescription records.

Legal requirement · Pharmacy Regulation Act s 32(4)(b)–(c) · Schedule cl 11(b)–(c)

Keeping prescription records

Prescription records are kept in a secure place at the pharmacy for at least 3 years (Pharmacy Regulation Act).
Because they are health records, keep them for at least 7 years after the patient's last service, or until a child patient turns 25 if that is later (Health Records Act).
They can be found by the patient's name and address, the date dispensed, or from the details on the label.

Legal requirement · Pharmacy Regulation Act s 32(4)(a) and (d) · Schedule cl 11(a) and (d) · Health Records Act 2001 HPP 4.2

Reference texts

Every pharmacist and other staff member, including locums, has ready access to current, evidence-based references that fit the services we provide. The licensee decides which, based on an assessment of the risks of those services.
Our baseline set is the Pharmacy Board's former reference list (Guideline 1): Australian Pharmaceutical Formulary and Handbook; Australian Medicines Handbook; Therapeutic Guidelines; an Australian product information source (AusDI or MIMS); a drug interactions reference updated quarterly; AMH Children's Dosing Companion; Don't Rush to Crush; an evidence-based complementary medicines resource; pharmacy legislation and standards; Australian Immunisation Handbook; PSA and SHPA professional standards; Pharmacy Board guidelines; MSD Manual (Professional Version).
It also has any other references our services need.
Online references are fine if they are available at the dispensing station.

Legal requirement · VPA Standards 1.2.6 and 2.6.1 · PBA Guidelines on the safe provision of pharmacy services 1.1 and "Reference material" · PBA Guidelines on practice-specific issues (Guideline 1 · titles as amended 18 Aug 2023; ended 30 Sep 2026)

Knowing the login details

Which references are held, how each is accessed — a shared login, a subscription, or where a printed copy sits — and when it's renewed should be kept in the pharmacy's references register, so every staff member who needs one, including locums, can find it.

Regulator guidance · VPA Guidelines G1.2.6

Vaccination references

Pharmacists who vaccinate should have ready access to the current online Australian Immunisation Handbook, the National Vaccine Storage Guidelines (Strive for 5) and the Victorian cold chain management protocols.

Regulator guidance · VPA Guidelines G2.6.1 · VPA self-audit 2.6.1

Using the dispensary

The dispensary is private and used only for dispensing, supplying and compounding medicines and for storing medicines and patient records.

Legal requirement · VPA Standard 2.4.1 · Schedule cl 4

Dispensary rules

- The public should never enter it, and only trained dispensary staff should work in it.
- It should not be used as a shortcut to back-of-house areas.
- Point-of-sale entry, clerical work, non-dispensary stock and staff areas should be outside it.
- Staff areas should be outside the dispensary, with belongings kept and meal and tea breaks taken outside it.
- Dispensing benches should be kept clear of anything not needed for dispensing.
- Dispensary computers should be used only for dispensing.

Regulator guidance · VPA Guidelines G2.4.1 · G2.4.9 and G1.3.2.1 · VPA self-audit 2.1.1 and 2.1.2

Supplying without the patient present

When dispensed medicines are delivered or supplied without the patient attending, the pharmacist still checks the supply, makes counselling available by phone, and makes sure the package keeps the medicine private and at the right temperature in transit.

Pharmacy's own choice · Schedule cl 9(f)

Premises

9. Premises security

Opening and closing, keys, the alarm, physical security, and changes to the premises.

Version 2 · approved 23 September 2026 by Sam Nguyen

Opening and closing

Because no one may be inside while the pharmacy is closed unless a pharmacist is present, a pharmacist opens and closes.
No one else enters while it is closed unless a pharmacist is present.

Legal requirement · Pharmacy Regulation Act s 31

Closing checklist

On closing, the pharmacist checks that doors and windows are locked, the S8 safe is locked, and the alarm is set.

Pharmacy's own choice · Pharmacy Regulation Act s 31

Keys, codes and swipe cards

Keys and other entry devices are held only by registered pharmacists the licensee has authorised.

Legal requirement · Schedule cl 3

Tracking keys and swipe cards

We keep a key register — the VPA recommends one — that records every key and card and who holds it.
Where it's kept: not yet recorded.
Swipe-card access, and any override keys, should be restricted to pharmacists.
Restricted keying — keys that cannot be copied at a hardware store — is highly recommended, and used where possible.

Regulator guidance · VPA Guidelines G2.3.1

A lost key

Lost keys are reported at once and locks changed if needed.

Pharmacy's own choice · VPA Guidelines G2.3.1

The alarm

The pharmacy has a working intruder alarm monitored 24 hours a day by an appropriately graded monitoring centre, or an on-site security service the VPA has approved.
It covers the perimeter and every area where medicines are kept: the dispensary, the S8 safe, the professional service area, storerooms and any DAA packing room.
The VPA expects the monitoring company to hold a security firm licence and be graded 1, 2 or 3 under AS 2201.2:2022. A silent duress alarm is recommended.
Monitored by Sentinel Security Monitoring — 1300 554 118.

Legal requirement · VPA Standard 2.3.3 · VPA Guidelines G2.3.3 · VPA self-audit 2.3.3

Doors, windows and ceilings

Doors, windows, skylights, walls and ceilings are substantially built and secured, with adequate perimeter security.
The VPA's expected measures are:
- front doors have substantial locks; perimeter doors to secluded or non-public areas are solid core reinforced with heavy-gauge metal sheeting or a security grille, or have roller shutters
- perimeter windows to secluded or non-public areas have bars or security grilles; skylights that open have bars, grilles or substantial locks; other opening windows have substantial locks
- the ceiling or roof space is protected against entry
- a dispensary door that can't always be watched closes itself and opens from outside only with a key, code or card.

Legal requirement · VPA Standards 2.3.1–2.3.2 · VPA Guidelines G2.3.1–G2.3.2 · VPA self-audit 2.3.1–2.3.2

Reporting a fault

Any damage or fault is reported to the licensee and fixed promptly.

Pharmacy's own choice · VPA Standards 2.3.1–2.3.2

Checking security works

Locks and physical security should be checked periodically, and the alarm and other electronic devices tested to confirm they work.

Regulator guidance · VPA Guidelines G2.3.1

Changes to the premises

The VPA must approve any significant alteration before work starts. That includes changes to the perimeter or its security, public access, the dispensary or access to it, a compounding or DAA room, or counselling areas.
If unsure whether a change is significant, ask the VPA first.

Legal requirement · VPA Standard 2.2.1 · VPA Guidelines G2.2.1

Premises

10. Cleaning, hygiene and equipment

Keeping the pharmacy clean, hand hygiene, the equipment register, maintenance and calibration, and simple compounding equipment.

Version 1 · approved 23 September 2026 by Sam Nguyen

A clean, uncluttered pharmacy

The pharmacy is kept clean, hygienic, organised and uncluttered.
A cleaning schedule is kept, and cleaning is recorded.

Legal requirement · Schedule cl 1(b) · VPA Standard 2.1.2

What the cleaning schedule covers

Benches, shelves, floors, sinks, fridges and air-conditioner filters — recording when each was done.

Pharmacy's own choice · VPA Guidelines G2.4.4 · VPA self-audit 2.4.4

Hygiene and infection prevention

- Hand hygiene should be practised before and after contact with a patient, after handling hazardous medicines, and after anything that could contaminate hands.
- Surfaces and equipment that touch medicines should be cleaned and disinfected regularly.
- Protective equipment suited to the task should be worn — for example, gloves when filling dose administration aids.
- Waste, including sharps, should be disposed of correctly.
- Staff should be trained in hygiene and infection prevention for their role.

Regulator guidance · VPA Standard 2.4.4 · VPA Guidelines G2.4.4

Equipment we use

Equipment should come from reputable suppliers, be fit for its purpose, and be used as the manufacturer instructs.
It should be inspected regularly for damage or wear, and kept safe from unauthorised use.
Faulty equipment should be taken out of use as soon as practicable, labelled as faulty, and repaired or replaced.

Regulator guidance · VPA Standard 2.5.1 · VPA Guidelines G2.5.1 · VPA self-audit 2.5.1

The equipment register

An equipment register should list each item and the maintenance, servicing and calibration it needs, and how often.
Where ours is kept: not yet recorded.
Each time maintenance is done, the log should record the date, what was done and who did it. External calibration should be done by an appropriately accredited provider using traceable standards, with the report — make, model and serial number, date, standard used, results, uncertainty and accreditation — kept.
Maintenance and calibration records should be kept for 5 years.

Regulator guidance · VPA Standards 2.5.2 and 2.5.5 · VPA Guidelines G2.5.2 and G2.5.5 · VPA self-audit 2.5

Operating instructions

Written operating instructions should be at the point of use for every item of equipment, and staff should be trained and assessed before using equipment that needs training.

Regulator guidance · VPA Standard 2.5.3 · VPA Guidelines G2.5.3

Cleaning equipment

Equipment should be cleaned on a schedule. Anything used for compounding or in contact with patients should be cleaned before and after each use.
Clean equipment should be stored dry, labelled with the date last cleaned, and checked before use — if it is not clean, it should be cleaned again.
Cleaning cloths and brushes should themselves be cleaned and stored properly.

Regulator guidance · VPA Standard 2.5.4 · VPA Guidelines G2.5.4 · VPA self-audit 2.5.4

Simple compounding equipment

The dispensary has, at a minimum:
- Class I or Class II scales approved by the National Measurement Institute, with the approval certificate on file, the operating instructions displayed, and the minimum weighable amount displayed prominently
- a range of accurately calibrated Class A measures, such as 10, 50, 100 and 200 mL
- a mortar and pestle, an ointment slab and a range of spatulas
- suitable storage containers.
The VPA expects scales to be externally validated and calibrated at least once a year.

Legal requirement · VPA Standard 2.5.6 · VPA Guidelines G2.5.6 and G2.5.3 · VPA self-audit 2.5.6

Premises

11. Dispensary layout and fit-out

What the dispensary must have — sink, fridge, dispensing stations, benches, counselling points and lighting — and checking it still fits the workload.

Version 1 · approved 23 September 2026 by Sam Nguyen

A dispensary fit for its work

The dispensary is sized and equipped for the services the pharmacy provides and the number of prescriptions it dispenses.
Its adequacy is checked again whenever the business grows or changes.

Legal requirement · VPA Standard 2.4.2 · VPA Guidelines G2.4.2

What the dispensary has

- A sink with an integrated drainer and hot and cold running water. A hand basin alone is not enough.
- A refrigerator used only for medicines, with temperature monitoring (see Cold chain).
- A storage system that keeps medicines secure and makes it easy to pick the right one.
- A dedicated safe or vault for Schedule 8 and 9 poisons that meets the drugs and poisons regulations and holds all stock on hand (see Schedule 8 medicines).

Legal requirement · VPA Standard 2.4.2(a)(b)(e)(f) · VPA Guidelines G2.4.2

Dispensing stations

There should be one dispensing station for every 150 prescriptions, or part thereof, dispensed on a typical day between 9 am and 6 pm.
Each station should have a bench of at least 0.6 m², a screen and keyboard, its own barcode scanner, its own label printer and repeat printer, stationery, and access to a printer for Consumer Medicine Information.

Regulator guidance · VPA Standard 2.4.2(c) · VPA Guidelines G2.4.2

Bench space

As well as the dispensing stations, the dispensary should have benches of at least 0.6 m² each for:
- simple compounding, near the sink, with storage for measuring and weighing equipment
- unpacking and sorting orders
- clerical and research work.

Regulator guidance · VPA Standard 2.4.2(d) · VPA Guidelines G2.4.2

Dose administration aid packing area

If the pharmacy regularly packs dose administration aids for 15 or more people a week, there should be a dedicated bench of at least 1 m² for it, with secure storage for dispensed medicines.
A packing area away from the dispensary should be air-conditioned, alarmed, near hand-washing facilities, have a computer for looking up patient histories and printing, have lockable storage, and be free from interruption.

Regulator guidance · VPA Guidelines G2.4.2 and G2.4.13

Counselling points

There should be as many prescription reception and counselling points as dispensing stations.
Each should have opaque privacy screens rising at least 600 mm above the bench, or be otherwise arranged so conversations are private.
The layout should keep customers from standing directly in front of the dispensary except at these points.

Regulator guidance · VPA Guidelines G2.4.2 and G2.4.6 · VPA self-audit 2.4.1

Light and temperature

The dispensary is well lit over every work surface, adequately ventilated, and temperature-controlled (see Cold chain for the 25°C limit).

Legal requirement · VPA Standard 2.4.3 · VPA Guidelines G2.4.3

People

12. Staff, training and workforce

Checking registration, training and records, position descriptions, staffing levels, locums, and working within scope.

Version 4 · approved 27 September 2026 by Sam Nguyen

Checking pharmacist registration

Every pharmacist's registration, including locums', should be checked on the Ahpra register before they start and at least once a year after that.
Any conditions on their registration should be noted, and their duties kept within them.

Regulator guidance · VPA Standard 1.2.2 · VPA Guidelines G1.2.2 · VPA self-audit 1.2.2

Professional indemnity insurance

Every pharmacist working here, including locums, should be covered by professional indemnity insurance that meets the Board's registration standard.
Where the pharmacy arranges that cover for employed pharmacists, evidence that it is current should be available to them.

Regulator guidance · PBA Guidelines on the safe provision of pharmacy services (Introduction) · VPA Guidelines G1.5.3

Position descriptions

Every role should have a written position description that reflects what the person actually does and the qualifications or training it needs — pharmacist, pharmacist immuniser, dispensary assistant or technician, and so on.

Regulator guidance · VPA self-audit 1.2.3 · PBA Guidelines on the safe provision of pharmacy services 1.2(c)

Dispensary assistant training

Before dispensary assistants and technicians help with dispensing, the licensee should identify the training their role needs and support them to complete it.
Anyone who helps with compounding should have completed the training the Board requires for it.
Certificates or other evidence of training should be kept at the pharmacy.

Regulator guidance · VPA Guidelines G1.2.3 · PBA Guidelines on the safe provision of pharmacy services 1.2(c)–(e)

Pharmacist immunisers

Only pharmacists who have completed an immuniser program recognised by Victoria's Chief Health Officer give vaccines, and only as the current Secretary Approval for Pharmacist Immunisers and program guidelines allow.

Legal requirement · Secretary Approval for Pharmacist Immunisers (Gazette S 535 · 3 Oct 2024) · VPA Guidelines G1.2.3 · Victorian Pharmacist-Administered Vaccination Program Guidelines

Immuniser and first-aid records

Their immuniser certificate should be kept in the vaccination area.
Their first aid and CPR certificates should be kept current and on their training record.

Regulator guidance · VPA Guidelines G1.2.3 · VPA self-audit 1.2.3

Training records

Each staff member should have a training record covering induction, training on the pharmacy's policies and procedures, courses completed, and certificates with their expiry dates.
Records should be kept up to date, and staff should keep their knowledge current through ongoing learning.

Regulator guidance · VPA Guidelines G1.4.3 and Appendix 2 · VPA self-audit 1.2.3

Working within scope

Pharmacists should work within their competence, and other staff should do only the tasks they have been trained for.
Across the team there should be the mix of skills and experience the pharmacy's services need.

Regulator guidance · VPA self-audit 1.2.3

Enough staff

The pharmacy should be staffed for its expected workload and services, with clear lines of responsibility.
As a benchmark, there should be at least one full-time-equivalent pharmacist for every 150 prescriptions dispensed on an average day, pro rata at weekends and on public holidays.
The roster should allow for predictable spikes in activity and for time spent on non-dispensing work such as checking dose administration aids, immunisation and pharmacist prescribing services.

Regulator guidance · VPA Standard 1.2.4 · VPA Guidelines G1.2.4 and G1.2.4.1 · PBA Guidelines on the safe provision of pharmacy services 1.2(b)

Planned and unplanned absence

The pharmacy should know in advance how it will cover a pharmacist's absence: first Daniel Okonkwo — 0412 884 301. See Who is in charge — When the PRUIC is away for the full steps.
If no pharmacist can be found, the pharmacy does not open without one.

Regulator guidance · VPA self-audit 1.2.4 and 1.1.2 · Pharmacy Regulation Act s 30

Locum induction

A locum should get a full induction before their first shift: the policies and procedures, the dispensing software, where the references are and how to log in, opening and closing, and the dispensary layout.
They should be given the contact numbers they need, such as for the PRUIC (Marisa Toldo) and the licensee (0413 662 907).

Regulator guidance · VPA Guidelines G1.2.4.1

Targets never override judgement

No sales target, incentive or business goal should ever be allowed to override a pharmacist's professional judgement about what is safe and appropriate for a patient.

Regulator guidance · VPA self-audit 1.2.5