Fam

All rights reserved.
No part of this document may be reproduced or transmitted,

in any form or by any means, electronic, photocopying or otherwise without prior
written permission from the Ministry of Health, Malaysia.
Ministry of Health, Malaysia

FRB/HIS/PhIS/2006/Version 1.1
ISBN: 983-9417-53-3
Date Created: August 2005
First Edition: July 2006
Copyright @ Ministry of Health Malaysia

FOREWORD
Tan Sri Datuk Dr. Haji Mohd. Ismail Merican
Director General of Health, Malaysia
Malaysia being progressive in the adoption of Information communication “Technology in Health

Care” has embarked in the creation of ICT enabled facilities. The Telemedicine blueprint “Leading
Healthcare into Information Age” has laid the foundation for the planning and implementation of
ICT initiatives in the country. Amongst the building blocks that has been recognised as vital for
interoperability was the development and adoption of Health Informatics Standards.
The Ministry of Health has played a leading role in the development of Health Informatics Standards.
In collaboration with stakeholders in the public and private sector, several standards have been
developed for adoption in the country. Amongst them include the “Functional Requirements Brief”
that has been prepared to provide functional requirements of the core business of the hospital
as an entity. The business functional model including business functions, operational policies,
high level work flows and system functionalities are well documented. This document would
provide the health care personnel as to how the work processes and procedures are streamlined
in a computerised working environment and for the system developers, it provides an in depth
understanding of the user needs.
The documents that have been developed includes the
• Person Management System

• Pharmacy Information System
• Laboratory Information System
• Radiology Information System
• Blood Bank Information System
• Oral Health Information System
• Operation Theatre Management System
I wish this document be used as a generic standard in the development and customization of
hospital information system being deployed in the hospitals in the country. I take the opportunity to
congratulate the expert group that has put in countless number of man hours for the preparation of
the document and all members of the consensus meeting for their participation and contribution.
TAN SRI DATUK DR. HAJI MOHD. ISMAIL MERICAN

DIRECTOR GENERAL OF HEALTH, MALAYSIA
Vision for health
Malaysia is to be a nation of healthy individuals, families
and communities, through a health system that is equi-
table, affordable, efficient, technologically appropriate,
environmentally-adaptable and consumer-friendly, with
emphasis on quality, innovation, health promotion and
respect of human dignity and which promotes individual
responsibility and community participation towards an
enhanced quality of life.
mission OF THE MINISTRY OF HEALTH

The mission of the Ministry of Health is to build partnership
for health to facilitate and support the people to :
• Attain fully their potential in health.

• Motivate them to appreciate health as valuable
asset.
• Take positive action to improve further and sustain
their health status to enjoy a better quality of life.
PHARMACY INFORMATION SYSTEM
BUSINESS FUNCTION MODEL
MEDICATION ORDER MANAGEMENT MODULES

1. Name of The Department 7
2. Business Function 7
Contents
3. Range of Services 7
4. Types of Services 7
5. Clients 7
6. Operational Policies 7
7. High Level Workflow 12
8. Mapping of the Work Process / 23

System Functionality / Operational
Policy
9. Assumptions 54
10. Glossary 55
11. Abbreviations 56
BUSINESS FUNCTION MODEL PHARMACY INFORMATION
SYSTEM
1. Name of the department: Pharmacy Department.
2. Business Function: Medication Order Management.
3. Range of services:-
3.1. Outpatient Order.

3.2. Inpatient Order.
3.3. Inter Pharmacy Order.
4. Types of Services:-
4.1. Outpatient Medication Order:-
4.1.1. Dispensing.
4.1.2. Counselling.
4.2. Inpatient Medication Order:-
4.2.1. Unit Dose/Unit of Use.

4.2.2. Discharged/Bedside Dispensing.
5. Clients:-
5.1. Internal Clients:-
5.1.1. Within Hospital.

5.1.2. Within Enterprise (Pharmacy to Pharmacy).
5.2. External Clients:-
5.2.1. Other than MOH Healthcare Facilities.
6. Operational Policies:-
6.1. Medication Order:-
6.1.1. All medication orders must be prescribed by authorised personnel only

and in compliance with guidelines on prescribing in the drug formulary
(drug category, discipline / speciality) as defined by MOH.
6.1.2. All patients must be registered before medication orders are raised and
drugs prescribed must be specific for the registered patient only (This is
to ensure that the therapeutic need of the respective patient is captured
in the discharged summary and LHR, and is unique for the patient).
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6.1.3. The Medication Order shall consist of the following data elements:-
6.1.3.1. Patient biodata (name, age, sex, weight, height, MRN).

6.1.3.2. Diagnosis / problems.
6.1.3.3. Generic name of drug.
6.1.3.4. Dosage.
6.1.3.5. Frequency.
6.1.3.6. Duration.
6.1.3.7. Route of administration.
6.1.3.8. Known allergy.
6.1.3.9. Name, designation and location of prescriber.
6.1.3.10. Date and time of medication order.
6.1.4. The medication order of a particular drug is considered valid for the
duration prescribed from the date of prescribing.
6.1.5. For medication orders of non registered drug, coding shall be assigned
by the Pharmacy Division, MOH.
6.1.6. The system shall be able to provide information to specify the ordered
items as per local drug formulary, MOH and non-MOH including registered
& non-registered drugs. This function is to enable data mining.
6.1.7. The pharmacist shall be given access to relevant clinical information as

contained in EMR.
6.1.8. The pharmacist shall be authorised to make clinical entries into the EMR as
and when necessary during patient consultation or clinical intervention.
6.1.9. Modification or cancellation of the order can only be done by the prescriber
himself or by another personnel assigned to cover his duty during his
absence.
6.1.10. The pharmacist shall be authorised to modify the medication order upon
consultation with the prescriber.
6.1.11. If medication orders are received for refill purposes from facilities
outside the enterprise, data entry shall be made by authorised pharmacy
personnel.
6.2. Dispensing:-
6.2.1. All prescribed drugs shall be verified / screened by the pharmacist before
dispensing (where applicable). In situations where there is no pharmacist,
the pharmacy assistant is given this authority. However, role assignment
shall be dependent on the hospital policy in relation to the supervisory
task that needs to be performed by specific staff.
8 PHARMACY INFORMATION SYSTEM (Version 1.1)
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6.2.2. All dispensing tasks should be carried out by trained personnel.
6.2.3. Bedside dispensing shall be practised for inpatient discharges.
6.2.4. Data capture for LHR / MyKAD shall be triggered at the point of dispensing
for outpatient medication orders and at the point of discharge for inpatient
medication orders.
6.2.5. Queried medication orders shall be rerouted to the care provider for
reorder/cancellation of medication order.
6.2.6. Valid medication orders refers to the period of care plan for which the
medication is prescribed.
6.2.7. Transaction for partial medication order and from those outside the
enterprise shall be registered prior to dispensing.
6.2.8. Request for refill medication orders from outside the enterprise shall
be accompanied by SPUB R1 Form and medication order/transcription
signed by authorised personnel.
6.2.9. Request for refill medication orders shall be confirmed via MyKad/LHR/
appointment slip.
6.2.10. A proxy may be allowed to collect medication on behalf of the patient

under special circumstances.
6.2.11. An audit trail shall be provided for the medication order cycle:-
6.2.11.1. place order.

6.2.11.2. receive order.
6.2.11.3. screen order.
6.2.11.4. verify order.
6.2.11.5. fill medication.
6.2.11.6. verify medication against order.
6.2.11.7. dispensing.
6.2.12. The process of medication supply shall start upon patient’s arrival time at
the pharmacy counter.
6.2.13. Drugs dispensed must be appropriately labelled with the following

information:-
6.2.13.1. Name of patient.

6.2.13.2. Generic name of drug.
6.2.13.3. Dosage.
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6.2.13.4. Frequency.
6.2.13.5. Batch number.
6.2.13.6. Manufacturer Name.
6.2.13.7. Amount.
6.2.13.8. Cautionary information.
6.2.13.9. Storage condition.
6.2.13.10. Dispensing date.
6.2.13.11. Expiry date.
6.2.13.12. Hospital/Clinic name and contact number.
6.2.13.13. The phrase ‘Ubat Terkawal’.
6.2.14. Medication not collected within the allowable period must be designated
as ‘uncollected medication’. However, uncollected medication can still be
dispensed if the medication order is still valid.
6.2.15. For medication orders using standard packs, the amount/ quantity
dispensed shall be subjected to predetermined local policy.
6.3. Management Report:-
The following reports shall be generated for the management of the Pharmacy
Department. All the frequency shall be weekly, monthly and yearly.
6.3.1. Statistic report:-
6.3.1.1. Prescribing pattern/trend.

6.3.1.2. Frequently / not frequently ordered drugs.
6.3.1.3. Slow moving items.
6.3.1.4. Drug usage by item, cost , discipline and prescriber.
6.3.1.5. The most expensive drug used.
6.3.1.6. Near expiry items.
6.3.2. Management report:-
6.3.2.1. Quality Assurance Programme.

6.3.2.2. Pharmacy Management.
6.3.3. Operational report:-
6.3.3.1. Partial supply.

6.3.3.2. List of medication orders.
6.3.3.3. Patient waiting time.
6.3.3.4. Outstanding order(s).
6.3.3.5. Uncollected item(s).
6.3.3.6. Patient medication profile.
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6.4. System Requirement:-
6.4.1. Ability to capture data for LHR/MyKAD shall be triggered at the point of
supply for all outpatient medication order and upon discharge for inpatient
medication order.
6.4.2. The system shall be able to provide information to specify the ordered items
as per local drug formulary, MOH and non- MOH list including registered
& non registered drugs. This function is to enable data mining.
6.4.3. The system shall be able to indicate the availability of stock for all items
listed in the orderable list.
6.5. The system shall be able to update inventory and charges (if applicable) upon
dispensing. Medication cost shall be available.
6.6. The system must be able to identify prescribed drugs according to:-
6.6.1. Drug category as defined in MOH Drug List.

6.6.2. Discipline / Specialty.
6.6.3. Doctor specific Medication order.
6.7. The system must be able to retrieve partial medication orders, activate the
medication order based on date of patient arrival and assign patient to queue.
6.8. The system shall enable the user to enter the details of medication order from
outside the enterprise e.g. SPUB. The referral document shall consist of the
following data:-
6.8.1. Referring healthcare facility.

6.8.2. Patient bio data (name, age, sex, weight, height, MRN).
6.8.3. Medication order details (name of drug(s), dosage, frequency,duration,route
of administration).
6.8.4. Diagnosis / problems.
6.8.5. Name, designation and location of prescriber.
6.8.6. Date and time of medication order.
6.8.7. Duration of supply.
6.8.8. Next supply date.
6.9. The system shall be able to capture collector’s identification (name/contact

number) during medication collection by proxy.
6.10. The system should capture the identity of persons involved in the process of
dispensing (screening, filling, dispensing) and recognize single or multiple roles
for the process of dispensing.
6.11. The system must be able to arrange the patient’s medication order based on
arrival time at the pharmacy counter.
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6.12. The system should be able to generate medication order slip if required.
6.13. The system must be able to generate drug labels with the following data:-
6.13.1. Name of patient.

6.13.2. MRN.
6.13.3. Name of drug.
6.13.4. Dosage.
6.13.5. Frequency.
6.13.6. Amount/quantity dispensed.
6.13.7. Cautionary information.
6.13.8. Storage condition.
6.13.9. Dispensing date.
6.13.10. Expiry date.
6.13.11. Batch Number.
6.13.12. Manufacturer Name.
6.13.13. Hospital/Clinic name and contact number.
6.13.14. The phrase ‘Ubat Terkawal’.
6.14. The system shall provide options for editing of drug label when extemporaneous
preparations/partial medication orders are dispensed/refilled.
6.15. The system shall be able to identify all filled Medication orders for uncollected
medication. The status shall be reported to CIS.
6.16. The system shall be able to denote all standard packing medication and the
amount to be dispensed shall be defaulted to predetermined amount.
6.17. The system shall be able to denote Dangerous Drug and Psychotropic Substances
dispensed and provide the information as required by Dangerous Drug Act 1952.
6.18. The system shall provide adequate security features in medication orders.
6.19. The system shall provide decision support for medications orders which will be
made available in both CIS and PhIS.
6.20. The system shall use Malaysian drug database for decision support for drug
information function and other pharmacy management activity.
7. High Level Workflow (depend upon scope of work of hospital):-
7.1. Outpatient Medication Dispensing Flow (Patient Flow)

– PhIS/OP/WF/1.
7.2. Outpatient Pharmacy Queue Management (Electronic Medication Orders)

Workflow
- PhIS/OP/WF/2.
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7.3. Outpatient Pharmacy Queue Management (External Clients) Workflow
-PhIS/OP/WF/3.
7.4. Outpatient Pharmacy Receiving And Screening of Medication Orders Workflow

– PhIS/OP/WF/4.
7.5. Outpatient Pharmacy Preparation of Medication Orders Workflow

– PhIS/OP/WF/5.
7.6. Outpatient Pharmacy Dispensing Of Medication Workflow

– PhIS/OP/WF/6.
7.7. Inpatient Pharmacy Screening Of Medication Order Except For Dangerous Drug
Orders (Unit of Use/ Unit Dose) Workflow
– PhIS/IP/WF/1.
7.8. Inpatient Pharmacy Supply of Medication (Unit Of Use/ Unit Dose) Workflow
– PhIS/IP/WF/2.
7.9. Inpatient Pharmacy Dispensing Of Medication for Discharged Patient – Including

Bedside Dispensing Workflow
– PhIS/IP/WF/3.
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OUTPATIENT MEDICATION DISPENSING FLOW (PATIENT FLOW)
PhIS/OP/WF1
· In-house medication
order Patient arrives at
· Refill pharmacy counter
· Pharmacy to pharmacy
within the facility
· Pharmacy to pharmacy Patient Acknowledge patient Queue
outside the facility identification arrival number
(Pharmacy Assistant)
Key-in medication
Within details
No
enterprise? (Pharmacist / Pharmacy
Assistant )
Yes
Verify medication order

(Pharmacist)
Rectify / verify by phone Is medication

No
(Pharmacist) order OK?
Yes
Approve medication order

(Pharmacist)
Print drug label Drug label

Fill medication orders

(Pharmacist / Pharmacy
Assistant )
Check orders
Assistant )
Rectify / verify
Correct? No (Pharmacist / Pharmacy
Assistant )
Yes
Dispense medication
Assistant )
Give appointment to
collect the balance Transcription
Full supply? No
Assistant )
Yes
Provide counseling Require

Yes
(Pharmacist) counseling?
No
End
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OUTPATIENT PHARMACY QUEUE MANAGEMENT WORKFLOW (ELECTRONIC MEDICATION
ORDER)
PhIS/OP/WF2
Patient arrives at
pharmacy
reception counter Pharmacy Reception Counter
Acknowledge patient
Queue
arrival and issue queue PhIS/
number
number OP/WF4
(Receptionist)
Check payment status

PMS
(Receptionist)
Record task &

Is it paying Billing
Yes document findings
patient? WF
(Receptionist)
No
Advice patient to wait for

collection of medication
(Receptionist)
PhIS/
OP/WF6
Note:
1. Check pharmacy display board to determine the order status for medication orders generated on the same day
2. Uncollected / refill medication order: to be registered at pharmacy registration counter
3. Billing module is not applicable in current pharmacy practice
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OUTPATIENT PHARMACY QUEUE MANAGEMENT (EXTERNAL CLIENT) WORKFLOW
PhIS/OP/WF3
Patient arrives at
pharmacy Pharmacy Reception Counter
reception counter
SPUB R1 form
Authenticate SPUB R1 form /
& medication
medication order
order
(Receptionist)
Register, acknowledge
Queue number patient arrival and issue PhIS/
queue number OP/WF4
(Receptionist)
Check payment status

(Receptionist)
Record task &

Is it paying Billing
Yes document findings
patient? WF
(Receptionist)
No
Advice patient to wait at

dispensing counter
(Receptionist)
Indicate queue number

& notify screening
counter
(Receptionist)
Forward SPUB R1 form &

medication order to
screening counter
(Receptionist)
PhIS/
OP/WF6
Note: External medication order need to be registered at the pharmacy counter
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OUTPATIENT PHARMACY RECEIVING AND SCREENING OF MEDICATION ORDERS
WORKFLOW
PhIS/OP/WF4
Note:
Does not include PN, CDR, Sterile Preparation and
PhIS/ Extemporaneous
OP/
WF2,3 Policy
The screening counter shall be responsible for making
order entry for all medication orders outside the facility
including CDR, Sterile and Extemporaneous
Check task list
Assistant )
Receive, SPUB R1 & medication

Is the order order (from receptionist), check,
within No verify and make order entry
enterprise? (Pharmacist / Pharmacy
Assistant )
Yes
Check medication order

status
(Decision Support) (Pharmacist)
· Drug dosage / schedule / route of
administration Receive, retrieve, verify and
· Drug duplication / incompatibility / Is it a new activate medication order for
interaction / contraindication
medication No partial supply
· Previous medication
order? (Pharmacist / Pharmacy
· MOH Institutional policy
Assistant )
· Drug availability
Yes
Check and verify

Inventory CIS/OP/
medication order status
workflow WF3
(Pharmacist)
Are there
Extemp Is it extemp
Yes No queries on the
workflow preparation?
order?
No Yes
Sterile Is it sterile Consult care provider

Yes
workflow preparation? (Pharmacist)
No
Record task &
document findings
CDR Is it CDR
Yes (Pharmacist)
workflow preparation?
No Inform care provider

Can the pharmacist
No and document findings
IV Is it IV modify order??
(Pharmacist)
Admixture Yes admixture
workflow preparation? Yes
Endorse modified medication
order (Care Provider)
Modify order
CIS
(Pharmacist)
Dosage, frequency, duration

and entry for comments
PhIS/OP/
No
WF5
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OUTPATIENT PHARMACY PREPARATION OF MEDICATION ORDERS WORKFLOW
PhIS/OP/WF5
PhIS/
OP/WF4
Check order for availability of

stock to determine duration
Inventory
of supply (refill / partial
substore
supply)
Does the medication

order include supply of
dangerous /
psychotropic drugs?
Yes
No
Validate and authorise
dispensing
(Pharmacist)
Select item and enter

quantity to be supplied
Assistant )
Generate fill list

(Pharmacist / Pharmacy Fill list
Assistant )
Print label
Extemp Labels
workflow
Assistant )
Prepare / fill medication

Sterile order
workflow (Pharmacist / Pharmacy
Assistant )
Check prepared medication

CDR
workflow
Assistant )
IV Need to edit /
Admixture reprint label?
workflow
Yes
No
Edit / reprint label
Labels (Pharmacist / Pharmacy
Assistant )
Update transaction / end

Billing preparation task
workflow (Pharmacist / Pharmacy
Assistant )
Send prepared medication to

dispensing counter
PhIS/
OP/WF6
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OUTPATIENT PHARMACY DISPENSING OF MEDICATION WORKFLOW
PhIS/OP/WF6
PhIS/
OP/WF5
Dispensing Counter
Check and verify

medication order against
medication prepared
Assistant )
Does medication Notify preparation counter

No and record task Report
match the order?
Yes
Call, identify patient and
verify order details with
episode summary CIS
Assistant )
Send back patient to the
Is medication for Inform prescriber and
prescriber PhIS/
the correct No document findings
(Pharmacist / Pharmacy OP/WF1
patient? (Pharmacist)
Assistant )
· Drug label
· Cautionary label
Yes · Generic name of drug
· Storage · Dosage
Is additional label · Frequency
condition label required? · Duration
· Route of administration
Yes
· Name, designation and location of
No prescriber
Labels Reprint label if required · Patient biodata (name, age, sex, weight,
(Pharmacy Assistant) height, MRN)
· Diagnosis / problems
· Appointment date (system generated
Determine payment status date)
PMS (Pharmacist / Pharmacy
Note: Applicable when
Assistant ) drugs are charged
Verify payment status

Is it paying Billing Transcription
Yes (Pharmacist / Pharmacy
patient? workflow
Assistant )
No
Is there a need Is it an in-

Print medication order
for subsequent Yes house Yes
supply? collection ?
No No
· Generic name of
Record task and Print SPUB R1 form & drug
document findings medication order to collect SPUB R1 form · Dosage
(Pharmacist / Pharmacy subsequent medication at & medication · Frequency
Assistant ) center of choice order · Duration
(Pharmacist / Pharmacy · Route of
Assistant ) administration
· Name, designation
Fax or post SPUB R1 form
Is the referral and location of
& medication order
within No prescriber
enterprise? · Patient biodata
Assistant )
Yes (name, age, sex,
weight, height, MRN)
Inform referred health · Diagnosis / problems
Record task and · Appointment date
facility on prescription
document findings (system generated
status
Dispense medication date)
(Pharmacist / Pharmacy · Name, signature, and
Assistant ) chop for Pharmacist /
Pharmacy Assistant
Counseling Is counseling
Yes
workflow required?
Note:
Dispensing includes partial supply and referred prescription for refill at other health facility
No
End
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Inpatient Pharmacy Screening of Medication Order Workflow
PhIS/IP/WF/1
CIS/IP/
WF/3
Raise medication
order
(Doctor)
Notify Pharmacist or Pharmacy

Is the order during office
No Assistant on -call
hour ?
(Staff Nurse /Medical Assistant )
Decision Support Yes

- Drug dosage /frequency & duration /route of admin .
- Drug incompatibilities , poly pharmacy Akcknowledge receive order Record task and document
- Critical drug interaction for medication findings
-contraindication (Pharmacist/ Pharmacy (Pharmacist or Pharmacy
-Previous medication Asst) Assistant)
- Profile of current medication
-MOH /Institutional drug policy
Checked & verify order
(Pharmacy Asst )
PIS/IP/WF/ Yes Is it PN order ?

PN
No
PIS/IP/
Yes Is it a cytotoxic drug ?
WF/CDR
No
PIS/IP/WF/
I.V Yes Is it I.V admixture ?
admixture
No
PIS/IP/WF/ Yes Is it a floor stock item ?

Floor Stock
No
PIS/IP/WF/
Sterile Yes Is it a sterile preparation ?
Preparation
No
PIS/IP/WF/ Decision Support
Yes Is it DD item? - Drug Dosage /Frequency & duration /Route of Admin .
DD
- Drug Incompatibilities , Poly Pharmacy
No - Critical Drug Interaction
-contraindication
Check and verify order -Previous medication
(Pharmacist) - Profile of current medication
-MOH /Institutional drug policy
-Emergency supply
Are there queries on

the order ?
Yes
Consult care provider

(Pharmacist)
Inform care provider and

Can Pharmacist modify
No document finding
order ?
(Pharmacist)
No
Yes
Modify orders
CIS
(Pharmacist)
Dosage , frequency , duration

Record task performed and
findings
(Pharmacist)
Is medication counselling Yes Counselling

required? Workflow
No
PhIS/IP/
WF2
Note: Extemporaneous preparations are excluded from this flow because screening is performed at the inpatient
pharmacy.
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Inpatient Pharmacy Supply of Medication (Unit of Use/ Unit Dose) Except For Dangerous
Drug Orders Workflow
PhIS/IP/WF/2
PhIS/IP/
WF/1
Types of medication order:-

-new order
-repeat order
Determine order status
(Pharmacist/Pharmacy Asst.) -emergency order
No New order?
Yes
Activate task list for
refill Any extemp. Extemp.
Yes
(Pharmacist/ preparation? W/F
Pharmacy Asst.)
No
Generate fill list

(Pharmacist/ Pharmacy Asst) Record task list
(Pharmacist/
Pharmacy
Assist.)
Fill list and label Print fill list & label
(Pharmacist/ Pharmacy Asst)
Fill patient medication

(Pharmacist/Pharmacy Asst.)
Counter check filled medication

No
Does medication match
with the supply list ?
Yes
Supply list Issue medication to Staff Nurse

(Pharmacy Asst.)
Record tasks performed and Billing &

Reports findings Inventory
(Pharmacist/ Pharmacy Asst) W/F
Check and acknowledge supply

(Staff Nurse)
CIS/IP WF
Medication
Administra-
tion
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Inpatient Pharmacy Dispensing of Medication For Discharged Patient - Including Bedside
Dispensing Workflow
PhIS/IP/WF/3
CIS/IP
Check and verify medication

order
(Pharmacist)
Are there queries on the

Decision Support order ?
-drug dosage/schedule/route of
admin. Yes
-drug duplication/ incompatibility / Consult prescriber
interaction/contraindication (Pharmacist)
-previous medication
Record task and document finding

No (Pharmacist)
No Inform prescriber (Pharmacist)

Can the pharmacist modify order ?
Yes
Endorse modified medication order
Modify order CIS (Care provider )
(Pharmacist)
Dosage , frequency , duration and

entry for comments
Does the medication order include supply
of Dangerous / Psychotropic Drugs ?
Yes
Validate and authorise dispensing

(Pharmacist)
No
Extemp W /F Yes Any extemp . preparation ?
No
Generate fill list Fill list

(Pharmacist/ Pharmacy Asst )
- Drug label .
Print labels Labels -Cautionary label
(Pharmacy Asst) -Storage condition label
Prepare/fill patient medication

(Pharmacy Asst)
Countercheck medication order

against items prepared
Need to edit / re-print label ?
Yes
Edit/ re-print label

Label (Pharmacist/ Pharmacy No
Asst.) Data Elements
-Generic name of drug
-Dosage
Update / end preparation task -Frequency
Billing W/F
(Pharmacy Asst) -Duration
-Route Of Administration
-Name, Designation and Location of
Transcription if in -house Prescriber
refill/ -Date and Time of Prescription
Is it a partial supply ?
SPBU R 1 Form & -Patient Biodata (Name, Age , Sex ,
medication form if refill at Weight, Height, MRN)
Yes other healthcare facility -Diagnosis / Problems
NO Print transcription
(Pharmacy Asst.)
Counsel patient Counselling

Is counselling required ? Yes W/F
(Pharmacist)
No
Dispense medication
(Pharmacist/Pharmacy
Asst.)
22 PHARMACY INFORMATION SYSTEM (Version 1.1) End
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MAPPING OF THE WORK PROCESS/
SYSTEM FUNCTIONALITY/OPERATIONAL POLICIES 8
NO ACTIVITIES SYSTEM FUNCTIONALITIES POLICIES
Outpatient Pharmacy - Queue Management (Electronic Medication Order) - PhIS/OP/WF/2.
1. Acknowledge • Ability to acknowledge patient arrival • All in-house medication

patient arrival at pharmacy counter, using MyKAD, order status from the
and issue queue barcode (patient identification) or clinics shall be displayed
number. transcription. on a monitor prior to
registration at pharmacy
• Ability to activate all medication orders counter.
for refill purposes and assign patient to
queue. • The priority of
medication supply will
• Ability to provide mapping of encounter be based on patient’s
number with queue number and arrival time at the
medication orders. pharmacy counter.
• Ability to capture time of patient • All patients arriving

acknowledgement when queue at the pharmacy
numbers are issued. department shall be
acknowledged and be
• Ability to show average waiting time at given the pharmacy
the display monitor. queue number.
• Ability to provide listing of medication • Queue management

order according to acknowledgement system must be
time so that staff manning respective interfaced with order
preparation workstation will prioritize management.
dispensing.
• Status of the medication
• Ability to provide listing of patient order and average
waiting at various location/clinics within waiting time shall be
specific time period in order to justify made known to the
needs of pharmacy staff. patient.
• Medication order task

list shall remain active
until expiry date and for
uncollected medication
orders.
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2. Check payment • Ability to link with PMS to check on • Patient shall be required
status. payment status. to produce guarantee
letter upon registration.
• Ability to link with HRMIS to check
on patient eligibility and verify • Online guarantee letter
employment status of government shall be accepted
servant. subject to MOH policy.
3. Record task • Ability to facilitate entries for

and document documentation of activities carried out.
findings.
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Outpatient Pharmacy - Queue Management (External Clients) - PhIS/OP/WF/3.
1. Register patient. • Ability to access registration module • All outpatients referred

for registration of patient from outside from outside the facility
the facility. shall be registered
prior to dispensing of
• Ability to provide encounter number for medication.
refill medication orders from outside
the enterprise. • All patients registered
at the pharmacy shall
be provided with an
encounter number.
2. Acknowledge • Ability to acknowledge patient arrival • The priority of

patient arrival at pharmacy counter, using MyKAD, medication supply will
and issue queue barcode (patient identification) or be based on patient’s
number. transcription. arrival time at the
pharmacy counter.
• Ability to provide mapping of encounter
number with queue number and • All patients arriving
medication orders. at the pharmacy
department shall be
• Ability to capture time of patient acknowledged and be
acknowledgement when queue given pharmacy queue
numbers are issued. number.
• Ability to show average waiting time at • Status of the medication

the display monitor. order and average
waiting time shall be
• Ability to retrieve medication orders made known to the
within the facility for dispensing via patient.
Integrated Supply (Pendispensan
Ubat-ubat Bersepadu) and assign
patient to queue.
• Ability to provide listing of medication

orders according to acknowledgement
time so that staffs manning respective
preparation workstation are able to
prioritize dispensing.
• Ability to provide listing of patients

waiting at various location/clinics
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within a specific time period in order

to assure adequate pharmacy staff
needs.
3. Check payment • Ability to link with PMS to check on • Patient shall be required
status. payment status. to produce guarantee
letter upon registration.
• Ability to link with HRMIS to check
on patient eligibility and verify • Online guarantee letter
employment status of government shall be accepted
servant. via HRMIS subject
to availability. The
screening counter shall
be notified.
4. Indicate queue • Ability to alert the screening counter • All refill and referral
number & notify at point of registration for all refill for SPUB medication
pharmacy medication orders including those from orders shall be notified
screening counter. outside the facility. to the screening counter.
5. Forward SPUB R1 • All SPUB R1 form &
form & medication medication order shall
order to screening be filed accordingly.
counter.
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Outpatient Pharmacy - Receiving And Screening Of Medication Orders - PhIS/OP/WF/4.
1. Check task list. • Ability to view medication orders/ • All medication orders
task list according to:- shall be screened for
• In-house medication order completeness and
status. appropriateness.
• Refill medication orders.
• Medication orders within the • All medication orders
facility for dispensing drug as within or outside
per Integrated Supply Policy enterprise shall
(Pendispensan Ubat-ubat conform to Integrated
Bersepadu). Supply Policy
(SPUB).
• Ability to alert and redirect
medication orders to relevant work • The screening
station for the following:- counter shall be
• Sterile preparation. responsible for
• Extemporaneous. making order entry
• CDR. for all medication
• IV Admixture. orders outside the
facility including
CDR, sterile and
extemporaneous, IV
admixture.
2. Check medication • Ability to denote new, refill and

order status. outside the facility (SPUB)
medication orders.
3. Check SPUB R1 • Ability to enable pharmacy • All order entries

form & medication personnel to enter the details of made for SPUB
order and make medication order from outside the shall be verified by
order entry. enterprise (SPUB). the pharmacist in-
charge.
4. Check and verify • Ability to access patient EMR if • Pharmacist shall

medication order. required. be given access
to relevant clinical
• Ability to provide decision support information.
on drug dosage, schedule to, route
of administration, incompatibility, • All drugs must
interaction. be prescribed by
authorized personnel
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• Ability to provide search as defined by MOH.
functionality for patented
proprietary drugs. • Access policy shall
be determined by the
• Ability to provide a summary of National Policy.
all previous medications and their
status such as refill dispensed • All drugs must be
“unattended” and “uncollected”. appropriately coded
with ATC/MDC
• Ability to repeat previous as approved by
medication orders (to be provided MOH. MDC code
under CIS also). shall be maintained
and updated by a
• Ability to provide alert on drug dedicated unit in the
duplication for drugs supplied and Pharmacy Division,
duration ordered within a specified MOH.
period of six months.
• All drugs shall
• Ability to link and access drug be categorised
monograph information database. according to
pharmacological
• Approved drug list and all other classifications.
DCA approved drugs with functions
to update, activate and inactivate, • The maximum period
discontinue formulary as and of each supply of any
when required. The system shall medication shall not
be able to maintain and indicate be more than three
the orderable items according to months.
the local drug formulary, MOH and
non-MOH.
• The system shall be able to • All medication

indicate the orderable items order shall contain
according to drug category as mandatory data
defined by MOH. element as defined
by MOH.
• Ability to provide search function
for medications according to • Medication order
alphabetical order in general and shall be categorised
pharmacological classifications as follows based on
(items within the groupings to be MOH local policy:-
arranged in alphabetical order). • Drug category.
• Discipline/
• Ability to search and map generic Specialty.
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name of drugs with its common • Doctor specific

trade name and generate medication order.
medication orderable in generic
term by default.
• Medication order to provide the

following data element:-
• Patient bio data (name, age,
sex, weight, height, MRN,
encounter number, queue
number.
• Diagnosis / episode summary.
• Generic name of drug.
• Dosage.
• Frequency.
• Duration.
• Route of administration.
• Name, designation and
Location of prescriber.
• Date and time of medication
order.
• For all medication orders on

‘when necessary basis’ (prn), the
instruction from the prescriber
should be defaulted in the system.
• Ability to indicate status of verified • All medication orders

medication order as screened. shall be verified in
accordance with
MOH or local policy.
5. Retrieve, verify • Ability to retrieve partial medication • Medication order

and activate orders and activates the of a particular drug
medication order medication order. is considered valid
for partial supply. for the duration
• Ability for the system to invalidate prescribed from the
medication order upon expiry of date of prescribing.
validity period for the medication
order. • Maximum and
minimum stock level
shall be determined
by local policy.
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6. Check order for • Ability to indicate stock availability • Indenting of
availability of at counter and sub-store level. medication to the
stock. main store shall be
• Ability to link to Inventory done in accordance
Management Module for:- to local policy.
• Checking of stock availability.
• Online indenting to main store.
7. Record the • Ability to provide entry for

consultation and documentation of task and relevant
findings. findings during consultation
activities.
• Ability to provide audit trail from

medication order to dispensing.
8. Modify order. • Ability to provide function for • Modifications made

modification of medication orders to medication orders
by Pharmacist and entry for any must be carried out
relevant reason. in consultation with
the prescriber or
• Ability to process the modified based on approved
medication order for dispensing local policy.
prior to co-sign.
• Modification or
• Ability to map modified or created cancellation of
new medication order upon queried the order can only
with the original medication order be done by the
number and queue number given prescriber himself or
to the patient. by another personnel
assigned to cover
• Ability to indicate the modification his duty during his
made to order to minimize any absence.
error in the process of supplying
the drugs. • For modification
done by Pharmacist
(dosage, frequency,
duration) such order
shall be confirmed by
prescriber or his/her
representative and
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shall be recorded in
EMR and authorised
by prescriber.
• Orders modified
by Pharmacist
/Pharmacy Assistant
after consulting the
prescriber must be
endorsed.
• For all medication

orders sent back to
the care provider
for modification or
writing of new order,
the queue number
patient should be
mapped with the
original and modified
medication order
number.
9. Inform care • Ability to support template for • All queries that

provider and reports on various type of queries. relate to medication
document • Ability to provide alert in CIS for:- order shall be
findings. • Endorsement of modified comprehensively
orders. and appropriately
• Queried medication orders. documented.
• Endorsement according to
MOH drug categories.
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Outpatient Pharmacy - Preparation Of Medication Orders - PhIS/OP/WF/5.
1. Check order for • Ability to link with the Inventory • Stock level at the
availability of Management Module to denote outpatient pharmacy
stock to determine stock level. shall be maintained
duration of supply at the sub-store.
(refill/partial • Ability to alert Pharmacy Assistant
supply). on the availability of stock
according to:-
• Minimum stock level.
• Maximum stock level.
• Status of stock level in main
store.
2. Validate and • Ability to capture essential • Validation and

authorise information for validating issuance issuance of
dispensing. of Psychotropics / Dangerous Psychotropics
Drugs:- / Dangerous
• Name of person validating and Drugs must be
issuing of the drug. in accordance
• Date and time of issuing. to Poisons
(Psychotropic
Substance) 1989 and
Dangerous Drugs Act
1952 respectively.
3. Select item and • Ability to interface with billing • Itemized costing of

enter quantity to module to provide itemised/ total medication orders
be supplied. costing of medication supplied. shall be made
available as and
• Ability to update stock level upon when required
filling. according to local
policy.
4. Generate fill list. • Ability to generate fill list for all

medication ordered.
5. Print labels. • The system must be able to • All drugs issued

generate drug labels with following and dispensed must
data:- be appropriately
• Name of patient. labelled.
• Name of drug.
• Dosage.
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• Frequency.
• Cautionary advice.
• Amount/quantity dispensed.
• Total cost of drug.
• Dispensing date.
• Expiry date.
• Hospital/Clinic name and
contact number.
• The phrase ‘Ubat Terkawal’.
• Ability to provide option for

selecting language of preference
for labels (Bahasa Malaysia/
English).
6. Edit /reprint label. • Ability to print and reprint drug • Only authorised
cautionary label and storage personnel are
condition label at the preparation allowed to edit,
and dispensing level. modify and reprint
• Ability to edit, modify instructions labels in accordance
on label. with MOH/local
policy.
7. Update • Ability to notify dispensing counter • All preparation

transaction / end on status of medication preparation of medication
preparation task. such as:- orders must be
• Not attended yet (by default). authenticated by the
• Being processed. personnel involved.
• Ready for dispensing.
• Ability to capture user identification

and password upon completion of
filled medication orders.
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Outpatient Pharmacy - Dispensing Of Medication - PhIS/OP/WF/6.
1. Check and verify • Ability to display all medication • All patients must be
medication orders and details of the registered before
order against medications filled. medication orders
medication are raised and
prepared. • Ability to indicate dispensing status drugs prescribed
according to the following:- must be specific
• Not attended yet (by default). for the registered
• Being processed. patient only (This is
• Ready for dispensing. to ensure that the
therapeutic need of
• Ability to provide entries for the respective patient
incident reporting on errors is captured in the
occurring during filling. (According LHR which is unique
to MOH predefined format). for the patient).
2. Call patient, • Ability to view episode summary to • Patient episode

identify and verify verify patient‘s medication order. summary shall be
order details with made available to
episode summary. relevant pharmacy
personnel.
• Patient shall be
identified by at least
two of the following:-
• Queue number.
• PMI.
• MyKad/IC.
• Follow-up
/appointment
card.
3. Notify preparation • Ability to alert preparation counter • Discrepancy

counter and personnel on any discrepancy pertaining to wrongly
record task. pertaining to fill medication and filled medication
change status to ‘on hold’. orders shall be
appropriately
• Ability to support template for documented.
documentation of wrongly filled
medication order.
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4. Reprint label if • Ability to print label as and when

required. necessary.
5. Inform prescriber • Ability to support template for • All queries on

and document reports on various type of queries. medication
findings. orders shall be
• Ability to link and provide alert comprehensively
in CIS for all queried medication and appropriately
orders. documented.
• Ability to denote all reviewed

medication orders as modified,
cancelled or amended.
• Ability to re-send to screening

counter and prioritise the
medication order.
6. Determine • Ability to indicate the payment

payment status. status such as paying or free as
rule base from the FIS.
7. Verify payment • Ability to indicate the payment • All payments shall

status. status such as paid or free. be done according to
MOH or local policy.
8. Dispense • Ability to integrate with MyKAD • Data captured for

medication. functionalities to record medications LHR for the purpose
dispensed. of medication
supplied shall be at
• Ability to update stock level upon
the dispensing level.
dispensing.
• Overlapping of supply within the • Reminder for refill

previous six months. medication order
shall be made
• Ability to indicate dispensed orders through PLHP
as complete and partial. services.
• Ability to purge and retrieve
dispensed order whenever required.
• Ability to provide a list of all partially

filled or uncollected medication
orders.
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• Ability to track the status of partial

filling of orders by patient and type
of medication such as name/code
of drug, pharmacological group.
9. Print • Ability to have an option to print • Transcription shall

transcription. transcription either in full or for consist of the
selected items only for balance following data:-
medication. Transcription details • Patient bio data
are as follows:- (name, age, Sex,
• Patient bio data (name, age, weight, height,
sex, weight, height, MRN). MRN).
• Diagnosis / problems. • Diagnosis /
• Generic name of drug. problems.
• Dosage. • Generic name of
• Frequency. drugs.
• Duration. • Dosage.
• Route of administration. • Frequency.
• Duration and quantity supplied • Duration.
and balance to be supplied. • Route of
• Name, designation and administration.
location of prescriber. • Duration
• Date and time of medication and quantity
order. supplied.
• Next collection date (for partial • Name,
supply only). designation
and location of
prescriber.
• Date and time of
medication order.
• Next collection
date (for partial
supply only).
10. Record task and • Ability to provide entry for

document finding. documentation of task and relevant
findings during dispensing activities.
• Ability to provide audit trail on

drugs prescribed and dispensed.
• Ability to capture user identification

and password upon completion of
filled medication orders.
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• Ability to indicate uncompleted tasks

and their reasons (for example
patient does not turn up to collect).
• Ability to purge the uncompleted

task on expiry of medication order.
11. Print SPUB R1 • Ability to generate SPUB R1 form • All collection of

form & medication & medication order for collection of medication at
order to collect medication at centre of choice. patient’s centre
subsequent of choice must be
medication at issued together with
centre of choice. SPUB R1 form &
medication order
as accordance to
Integrated Supply
(SPUB) policy.
• All SPUB R1 form

must be signed
by the authorised
personnel.
12. Inform referring • Ability to transmit medication order • Medication

health facility status electronically to the referred order status for
on prescription health facility (within enterprise all subsequent
status. only). collection of
medications at
patient’s centre
of choice (within
enterprise) must be
notified.
13. General function • Ability to provide access to Just • All dispensing

of dispensing. In Time – Continuing Pharmacy activities shall be
Education (JIT – CPE) and JIT- counterchecked by
MCPHIE. a second person
whenever the
• Ability to enable end user to situation permits.
operate the application as single or
multiple users.
• Ability to generate report for
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statistic, management and

operational purposes.
• Ability to generate report on

medication order and issuance of
Psychotropics/ Dangerous Drugs.
• Ability for reissue of medications

against loss or damage upon
dispensing if necessary.
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Inpatient Pharmacy - Screening Of Medication Orders (Unit Of Use/ Unit Dose) - PhIS/IP/WF/1.
1. Place medication • Ability to provide search function • All medication orders

order. for medications according to must be prescribed
alphabetical order in general and by authorised care
pharmacological classifications provider according to
(items within the groupings to be MOH drug prescribing
arranged in alphabetical order). policy.
• Ability to search and map generic • All medications

name of drugs with its common brought by patient
trade name and generate medication during the stay in
orderable in generic term by default. the ward/unit should
be surrendered
• Ability to indicate all medication back to patient upon
brought by the patient during the discharge.
stay in ward/unit.
• For all medication orders on

‘when necessary basis’ (prn), the
instruction from the prescriber should
be defaulted in the system.
2. Acknowledge, • Ability to receive and view • Drugs dispensed to

receive, check medication order which shall consist the ward shall be in
and verify of the following data:- conformity with unit
medication order. o Patient bio data (name, age, sex, dose/unit of use local
weight, height, MRN). policy.
o Patient location (ward/ bed
number). • Medication orders shall
o Diagnosis / problems. consist of the following
o Generic name of drug. data:-
o Dosage. o Patient bio data
o Frequency. (name, age, sex,
o Duration. weight, height,
o Route of administration. MRN).
o Name and designation of o Patient location
prescriber and discipline (unit) (ward/ bed number).
prescriber is attached to. o Diagnosis /
o Date and time of medication order problems.
o Medication order number. o Generic name of
drug.
• Ability to indicate the source of drug o Dosage.
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to be supplied such as floor stock, o Frequency.

patient’s own drug, investigational o Duration.
drug. o Route of
administration.
• Ability to generate a unique o Name, designation
medication order number as defined and location of
by local policy. prescriber and
discipline (unit)
• Ability to view relevant clinical prescriber is
information:- attached to.
o LHR. o Date and time of
o Clinical summary from CIS. medication orders.
o Medication order
• Ability to denote new and refill number.
medication orders.
• Ability to provide decision support

on drug dosage, schedule/route
of administration, incompatibility,
interaction (including CIS).
• Ability to link and access drug

monograph information database.
• Ability to receive medication orders

for patient referred from hospitals
within the enterprise (to consider
under CIS – day care).
• Ability to provide alert on drug • The maximum period

duplication for drugs supplied and for supply of any
duration ordered within a specified medication shall not
period of one week. exceed a period of one
week. Further supply
• Ability to override the previous order shall be made after
if there is a change in dosage for review.
same drug.
• The system shall be able to maintain • All drugs must be

and indicate the orderable items appropriately coded
according to the local drug formulary, with ATC/MDC as
MOH and non-MOH approved drug approved by MOH.
list and all other DCA approved
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drugs with functions to update, • Medication orders of

activate and inactivate, discontinue a particular drug are
formulary as and when required. considered valid for
the duration prescribed
• The system shall be able to indicate from the date of
the orderable items according to prescribing.
drug category as defined by MOH.
• Medication orders shall
• Ability to receive and view screened be governed by MOH
current medication orders for or local policy based
processing supplies. on:-
o Drug category.
o Discipline / Specialty.
o Doctor specific
prescription.
• Ability to view patient current • Supply of all category

medication profile detailing the A drugs shall be
following:- endorsed by consultant
o Current medication, amount in accordance to MOH
supplied previously and duration or local policy.
of supply.
o Change of medication, (dose, • Pharmacist shall
frequency, duration) and be given access
medication that has been stopped. to relevant clinical
o Category A and A* drugs information as
prescribed. contained in EMR.
• Ability to provide a summary of all • Pharmacists

previous medications and its related performing clinical
clinical summary with option to view pharmacy function
relevant EMR if required. shall be allowed to
make entries into the
• Ability to allow pharmacist EMR as and when
performing clinical pharmacy function necessary during
to make entries into the EMR as and medication counselling
when necessary during medication and all relevant
counselling and all relevant clinical clinical pharmacy
pharmacy interventional activities. interventional activities.
• Ability to link to Inventory • Indenting of medication

Management Module for:- to the main store shall
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o Checking of stock availability. be done in accordance

o Online indenting to main store. to local policy.
• Medication orders
arriving after pharmacy
working hour (subject
to local policy) will
be processed the
following day. During
this period supplies
can be obtained from
the floor stock.
• Ability to indicate status of screened • All medication orders

order as verified. shall be verified in
accordance with MOH
or local policy.
3. Determine the • Ability to indicate types of order such • Only authorized

type of order. as:- personnel are allowed
o PN. to redirect medications
o CDR. order to relevant work
o IV Admixture. stations.
o Sterile preparation.
o Floor Stock (DD & Non DD).
o Counselling.
o Emergency stock.
• Ability to enable the Pharmacist

or Pharmacy Assistant to redirect
medications order to relevant
workstations as above.
4. Inform care • Ability to support template for reports • All queries that relate to
provider and on various type of queries. medication order shall
document finding. be comprehensively
• Ability to link and provide alert in CIS and appropriately
for all queried prescription. documented.

modification of medication orders by Pharmacist to
by Pharmacist and entry for any medication orders
relevant remarks. must be carried out in
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• Ability to process the modified consultation with the

medication order for dispensing prior prescriber or based on
to co-sign. approved local policy.
• Ability to indicate modified • Modification or

medication order to prevent any cancellation of the
error in the process of supplying the order can be done
drugs. by the prescriber
himself or by another
personnel assigned
to cover his/her duty
during his absence or
his/her supervisor.
• All modification of the

orders as entered
by the Pharmacist
shall be endorsed by
the care provider for
designated person.
6. Record tasks • Ability to facilitate entries for • Details of the

performed and documentation of activities carried personnel on call and
findings. out. medications dispensed
shall be documented.
• Ability to capture details of the
personnel on call and provide audit
trail for after office hour inpatient
dispensing.
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Inpatient Pharmacy - Supply Of Medication (Unit Of Use/ Unit Dose) - PhIS/IP/WF/2.
1. Determine order • Ability to indicate types of order such • The maximum period
status. as:- for supply of any
o New order. medication shall not
o Refill. exceed a period of one
o Extemporaneous Order. week. Further supply
shall be made after
review.
2. Activate task list • Ability to automatically retrieve

for refill. medication orders for refill and
activate the medication order based
on due date.
3. Generate fill list. • Ability to indicate all medication • Supply of medication

orders that require immediate ordered will be in
supplies. accordance with pre
determined supply
time as defined
by local policy.
Any new order
(including change in
dosage, frequency
and duration) will
be attended to at
subsequent supply
time.
• For drugs ordered

between the supply
time requiring
immediate supply, the
pharmacy needs to be
informed by phone or
other means.
• The care provider shall

determine the status
of medication order to
indicate emergency
immediate routine
supply.
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4. Print fill list. • Ability to print fill list with system • Printing of fill list
generated unique serial number can only be done by
based on requested interval supply authorised personnel.
time.
5. Print label. • Ability to provide option for selecting • All drugs dispensed
language of preference for labels must be accurately
(Bahasa Malaysia/ English). labelled.
• Ability to print and reprint labels.

- Unit of Use/ Unit Dose Label:-
o Name of patient.
o PMI number.
o Bed number and ward.
o Name of drugs.
o Dosage and frequency.
o Amount supplied.
o Dispensing date.
• Ability to print and reprint drug

cautionary label and storage
condition label at the preparation and
dispensing level.
• Ability to provide options for editing

or to modify instructions on drug
label when required.
6. Notify preparation • Ability to alert preparation counter • Discrepancy pertaining

counter and personnel on any discrepancy to wrongly filled
record task. pertaining to filled medication and medication orders
change status to “on hold’. shall be appropriately
documented.
• Ability to support template for
documentation of wrongly filled
medication order.
7. Fill medication • All medication supplied

order. must be correctly
filled and labelled and
placed in a designated
container labelled with
patient’s name and
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Inpatient Registration
Number (IRN).
8. Countercheck • Fill list should incorporate name and • The person filling the
filled medication. designation of personnel involved in medication should
screening, preparation and supply of enter their name and
medication. sign on the fill list.
• Counter checking
and filling medication
should be done
preferably by different
persons.
9. Issue medication • Ability to record the identity of the • All medication issued
to staff nurse. receiver. shall be acknowledged
and signed by
• Ability to generate and print receiving personnel.
medication administration schedule Supply list shall
(if required). include date and time
of receipt.
• Ability to indicate the status of
medication administration schedule • Data regarding
(e.g. time administered, time due). medication given
to patient for LHR
• Ability to capture data for LHR/ shall be captured on
MyKAD shall be triggered at the discharge.
point of supply for in-patient.
Medication order should be triggered
at the point of administration.

10. Record tasks • Ability to document findings for all

performed and supplied medication.
findings.
medication order and supply status
from the time when medication order
is raised to time of dispensing.
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Inpatient Pharmacy - Dispensing Of Medication for Discharged Patient - Including Bedside

Dispensing - PhIS/IP/WF/3.
Note: Medication order screening and medication preparation process for bedside/discharge
dispensing are the same as for outpatient dispensing. As opposed to outpatient dispensing
where patients receive their medication at the counter, medication for all bedside/discharge
dispensing are prepared in the satellite pharmacy and supplied to the patient in their respective
wards.
1. View and check • Ability to view discharge medication • All drugs must
medication order. orders. be prescribed by
authorized personnel
• Ability to indicate and provide alert on as defined by MOH.
additional orders for the same patient.
• All drugs must be
• Ability to view request from prescriber appropriately coded
for medication counselling (checklist with ATC/MDC as
required). approved by MOH.
• Ability to provide a summary of all • All patients must be

previous medications and its related registered before
clinical summary with option to view orders (medication
relevant EMR if required. orders) are raised and
drugs prescribed must
• Ability to provide decision support be specific for the
on drug dosage, schedule/route registered patient only
of administration, incompatibility, (This is to ensure that
interaction (including CIS). the therapeutic need of
the respective patient
• Ability to provide a summary of all is captured in the LHR
previous medications. which is unique for the
patient).
• Ability to repeat previous medication
orders (to be provided under CIS • The maximum period
also). of supply for any
medication shall be in
• Ability to provide alert on drug the range of two weeks
overlapping of supply. to three months and
depends on status of
• Ability to access drug information availability of stock.
database.
• Ability to maintain the list of orderable consist of the following
data:-
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items according to changes made to o Patient biodata

the local drug formulary, MOH and (name, age, sex,
non-MOH approved drug list and weight, height,
all other DCA approved drugs with MRN).
functions to update, activate and o Diagnosis /
inactivate, discontinue formulary as problems.
and when required. o Generic name of
drug.
• Ability to indicate the orderable items o Dosage.
according to drug category as defined o Frequency.
by MOH. o Duration.
o Route of
• For all medication orders on ‘when administration.
necessary basis’ (prn), the instruction o Name, designation
from the prescriber should be and location of
defaulted in the system. prescriber.
o Date and time of
medication order.
• Pharmacist shall
be given access
to relevant clinical
information as
contained in EMR.
• Pharmacist shall
be authorised to
make entries into the
EMR as and when
necessary during
medication counselling
and all relevant
clinical pharmacy
interventional activities.
• Modification or
cancellation of the
order can only be
done by the prescriber
personnel assigned to
cover his duty during
his absence.
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• Pharmacist shall be
authorised to modify
the medication order
upon consultation with
the prescriber.
• Medication order of
a particular drug is
considered valid for
the duration prescribed
from the date of
prescribing.

be governed by MOH/
local policy based on:-
o Drug category.
o Discipline / Specialty.
o Doctor specific
prescription.
• Ability to indicate status of screened • All medication orders

order as verified. shall be verified in
accordance with MOH
or local policy.
2. Record task • Ability to provide entry for

and document documentation of task and relevant
findings. findings during preparation and
dispensing activities.
• The system should capture the

identity of persons involved in the
process of dispensing (screening,
filling, dispensing) and recognize
single or multiple roles for the process
of dispensing.

modification of medication orders by to medication orders
Pharmacist and entry for any relevant must be carried out in
remarks. consultation with the
prescriber or based on
• Ability to process the modified approved local policy.
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medication order for dispensing prior • All modification shall be

to co-sign. endorsed by the care
provider.
• Modification or
cancellation of the
order can only be
done by the prescriber
personnel assigned to
cover his duty during
his absence.
• For modification
done by pharmacist
such order shall
be confirmed by
prescriber or his/her
representative and
shall be recorded in
EMR and authorised by
prescriber.
4. Validate and • Ability to capture essential • Validation and issuance

authorise information for validating issuance of of Psychotropics/
dispensing. Psychotropics/ Dangerous Drugs:- Dangerous Drugs must
o Name of person validating and be in accordance to
issuing of the drug. Poisons (Psychotropic
o Date and time of issuing. Substance), 1989 and
Dangerous Drugs Act
1952 respectively.
5. Make entry • Ability to interface with billing module • Itemised costing of

for medication to provide itemised/ total costing of medication orders shall
supplied. medication supplied. be made available as
and when required
according to local
policy.
6. Print, edit or • Discharge Medication Label:- • All drugs issued and

reprint labels. • Name of patient. dispensed must be
• PMI number. appropriately labelled.
• Name of drug.
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• Dosage.
• Frequency.
• Amount/quantity dispensed.
• Batch Number.
• Cautionary information.
• Dispensing date.
• Expiry date.
• Cost.
• Hospital/Clinic name and contact
number.
• Ability to provide option for selecting

language of preference for labels
(Bahasa Malaysia/ English).
7. Check medication • Ability to provide entries for incident

supplied against reporting on errors occurring during
medication orders. filling (according to MOH predefined
format).
8. Update/ end • Ability to capture user identification • All preparation of

preparation task. and password upon completion of medication orders must
filled medication orders. be authenticated by the
personnel involved.
• Ability to indicate uncompleted task
and reasons (for example patient • Uncompleted task
does not turn up to collect). will remain active
until expiry date of
• Ability to purge the uncompleted task medication order
on expiry of medication order. according to the local
policy.
9. Print transcription. • Ability to have an option to print • Transcription shall

transcription either in full or for consist of the following
selected items only for balance data:-
medication. Transcription details are • Patient bio data
as follows:- (name, age, sex,
• Patient bio data (name, age, sex, weight, height,
weight, height, MRN). MRN).
• Diagnosis / problems. • Diagnosis /problems.
• Generic name of drug. • Generic name of
• Dosage. drug.
• Frequency. • Dosage.
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• Duration. • Frequency.
• Route of administration. • Duration.
• Duration and quantity supplied and • Route of
balance to be supplied. administration.
• Name, designation and location of • Duration and
prescriber. quantity supplied.
• Date and time of medication order • Name, designation
• Next collection date (for partial and location of
supply only). prescriber.
• Date and time of
• Ability to generate transcription if medication order
required. • Next collection date
(for partial supply
• Ability to reprint transcription by only).
authorized personnel.
10. Dispense • Ability to indicate dispensed orders.

medication.
• Ability to purge and retrieve
dispensed order whenever required.
• Ability to provide a listing of all

partially filled orders.
• Ability to track the status of partial

filling of orders by patient and type of
medication.
• Ability to denote all standard packing

medication and the amount to be
dispensed shall be defaulted to
predetermined amount.

• Ability to provide alert on discontinued

medication order, stoppage of
partial supply order, indication on
balance available in the ward and
update inventory when medication is
returned.
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• Ability to provide staff management

function on day-to-day basis based on
workload.

drugs prescribed, dispensed and
administered.
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9 ASSUMPTIONS
9.1. Provision of adequate security features for medication orders.
9.2. Decision support for medications orders will be made available in both CIS and PhIS.
9.3. Malaysian drug database shall be used for decision support for drug information function
and other pharmacy management function.
9.4. All medications supplied to patients shall be updated in the EMR upon dispensing for
outpatient medication orders and upon discharge for inpatient medication orders.
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GLOSSARY 10
No Terms Definition
1. Floor Stock. Floor stock items are common user drugs such as Paracetamol
and Vitamins.
2. After office hour After office hour stock items are drugs kept in respective
stock. ward which can only be used when needed after pharmacy
working hour.
3. Unattended An unfilled medication order, which has to be reactivated

medication order. when patient comes to collect the medication.
4. Uncollected A medication order, which has been filled but patient has not
medication order. collected the medication.
5. Medication Order. An order that has been prescribed by authorized personnel.
6. MOH Drug Category. Category of drugs as specified by MOH Drug List.
7. Transcription. A system generated document for activation of medication

orders for refill within enterprise.
8. SPUB R1 Form. A system generated document for collection of refill

medications outside enterprise.
9. Authorised Doctors, Pharmacists, Medical Assistants, Staff Nurses,

personnel. Community Nurses.
10 Within enterprises. Within hub in term of system infrastructure.
11. Within Hospital. In hospital.
12. Unit Of Use. Supply of medications to inpatient through medication order

on individual basis for a fixed period of time.
13. Unit Dose. Supply of medications to inpatient through medication order

on individual basis and daily basis.
14. Single Role. Refers to a single end user who is involved in the entire
process of dispensing (screening, filling and issuance of
medication).
15. Multiple Role. Refers to different end users who are involved in the process
of dispensing (screening, filling and issuance of medication).
16. Waiting Time. Period from acknowledgement time to dispensing time.
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11 ABBREVIATIONS
No Terms Definition
1. CDR. Cytotoxic Drug Reconstitutions.
2. CIS. Clinical Information System.
3. DCA. Drug Control Authority.
4. DD. Dangerous Drugs.
5. EMR. Electronic Medical Record.
6. HRMIS. Human Resource Management Information System.
7. JIT – CPE. Just In Time – Continuing Pharmacy Education.
8. JIT- MCPHIE. Just In Time – Mass Customised Personalised Health

Information & Education.
9. LHR. Lifetime Health Record.
10. LHS. Lifetime Health Summary.
11. MOH. Ministry Of Health.
12. MRN. Medical Record Number.
13. MyKAD. Malaysian Kad Akuan Diri.
14. PhIS. Pharmacy Information System.
15. PLHP. Personalised Lifetime Health Plan.
16. PMS. Person Management System.
17. PN. Parenteral Nutrition.
Sistem Pendispensan Ubat-Ubatan Bersepadu (Integrated

18. SPUB. Drug Dispensing System).
19. TDM. Therapeutic Drug Monitoring.
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CLINICAL PHARMACY AND MANUFACTURING MODULES

1 Name of The Department 59
2 Business Function 59
Contents
3 Range of Services 59
4 Types of Services 59
5 Clients 60
6 Operational Policies 60
7 High Level Workflow 66
8 Mapping of the Work Process / 81

Policy
9 Assumptions 113
10 Glossary 114
11 Abbreviations 116
BUSINESS FUNCTION MODEL PHARMACY INFORMATION
SYSTEM
1. Name of the Department – Pharmacy Department.
2. Business Function – Clinical Pharmacy and Manufacturing.
3. Ranges of Services:-
3.1. Drug Information Service.

3.2. Counselling.
3.3. Clinical Patient Management.
3.4. Manufacturing – Applies for compounding, reconstitution, dilution and storage of
sterile and non sterile drugs, repacking of bulk products.
4. Type of Services:-
4.1. Drug Information Service:-
4.1.1. Dissemination of information to healthcare providers and public.
4.2. Counselling:-
4.2.1. Inpatient.
4.2.2. Outpatient.
4.3. Clinical Patient Management:-
4.3.1. Clinical Pharmacokinetics Services.

4.3.2. Monitoring Medication Management.
4.3.3. Adverse Drug Reaction Monitoring.
4.4. Manufacturing:-
4.4.1. Sterile Products:-

4.4.1.1. Parenteral Nutrition.
4.4.1.2. Cytotoxic Drug Reconstitution.
4.4.1.3. Intravenous Admixture.
4.4.1.4. Eye Drop.
4.4.2. Prepacking Medicine:-

4.4.3. Extemporaneous Preparation.
4.4.4. Manufacturing Galenical Products.
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5. Clients:-
5.1. Internal Clients:-
5.1.1. Within Hospital.

5.1.2. Within Enterprise (Pharmacy to Pharmacy).
5.2. External Clients:-
5.2.1. Other than MOH Healthcare Facilities.
6.1. Drug Information Services:-
6.1.1. To provide information for the users at the point of care:-
6.1.1.1. List of drugs the Healthcare Provider is allowed to prescribe.

6.1.1.2. Dosage (dosage form, doses in various disease conditions such
as liver failure, renal failure, geriatrics, paediatrics, pregnancy.
6.1.1.3. Indications.
6.1.1.4. Contraindications.
6.1.1.5. Drug interaction/incompatibility.
6.1.1.6. Adverse reactions.
6.1.1.7. Precautions/caution.
6.1.1.8. Stability (e.g.: expiry date).
6.1.1.9. Reconstitution.
6.1.1.10.Diagnosis related drug list.
6.1.1.11.Availability.
6.1.1.12.Pharmacodynamics/Kinetics.
6.1.1.13.Monitoring Parameters.
6.1.2. To trigger information regarding:-
6.1.2.1. Drug to drug interaction.

6.1.2.2. Contraindication.
6.1.2.3. Precaution.
6.1.2.4. Alert on refills and non-compliances.
6.1.2.5. Poisoning.
6.1.2.6. Over dosages.
6.1.2.7. Sub therapeutics drug levels (Therapeutic Drug Monitoring -
TDM).
6.1.3. To provide information automatic dosage calculation based on body

weight, body surface area (BSA), creatinine clearance (CrCL), body
mass index (BMI).
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6.1.4. To provide information on drug availability on-site (stock inventory) and
update MOH and Instituitional Formulary.
6.2. Decision Support Services:-
6.2.1. Use of Standard Reference for Drug Information Service through the
National Drug Database (NDD):-
6.2.1.1. The database shall be updated minimum twice yearly by

Pharmaceutical Division, MOH.
6.2.1.2. In the event the drug name is not available from the database,
the decision support information shall be obtained from the Third
Party Database to be made available in the Pharmacy Information
System.
6.2.2. Access to Data Elements for Decision Support

Access to National Drug Database shall be provided to the following
category of healthcare providers:-
6.2.2.1. Doctors.
6.2.2.2. Pharmacists.
6.2.2.3. Pharmacy Assistants.
6.2.2.4. Medical Assistants.
6.2.2.5. Nurses.
6.2.3. Data elements for dosage calculation shall include the following
parameters:-
6.2.3.1. Age group.

6.2.3.2. Body weight and Body Surface Area. (BSA) and Height.
6.2.3.3. Creatinine Clearance in Renal impairment.
6.2.3.4. Specific data elements for preparation of PN, CDR, IV Admixture
and TDM.
6.2.3.5. Unit of Measure is in metric.
6.2.4. Data elements for parameters for indication to include the following:-
6.2.4.1. Complaints.
6.2.4.2. Diagnosis.
6.2.4.3. Signs and symptoms.
6.2.4.4. Procedures (i.e. Therapeutics, prophylactic or diagnostics).
6.2.4.5. Comparative drugs.
6.2.4.6. Poisoning.
6.2.5. Data elements for parameters for contraindication, precaution/caution to

include the following:-
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6.2.5.1. Allergy.
6.2.5.2. Pregnancy.
6.2.5.3. Breast feeding.
6.2.5.4. Age group.
6.2.5.5. Glucose -6- Phosphate Dehydrogenase (G6PD) deficiency.
6.2.5.6. Hypersensitivity.
6.2.5.7. Disease conditions.
6.2.6. Data elements for parameters for drug interaction:-
6.2.6.1. Drug to Drug.

6.2.6.2. Drug to Food.
6.2.6.3. Drug to Alcohol.
6.2.6.4. Drug influencing lab tests.
6.2.7. Data elements for detecting incompatibility between the ingredients used
in the preparation of CDR/PN / IV Ad & Eye Drop:-
6.2.7.1. Type of drugs/ingredients.

6.2.7.2. Type of solutions/medium.
6.2.8. Data elements for automatic calculation of ingredients used in the

preparation of CDR/PN/IV Ad/& Eye Drop:-
6.2.8.1. Automated calculation modules based on predetermined

parameters.
6.2.8.2. Data elements for Clinical Pharmaceutical Services (CPS).
6.2.8.3. Pharmacokinetics of relevant drugs according to predetermined
lists as approved by KKM.
6.2.8.4. CPS calculation modules.
6.2.9. For Adverse Drug Reaction (ADR) reference shall be made in the
National Drug Database and knowledge database. e.g. MICROMEDEX,
LEXICOMP:-
6.2.9.1. Stability of extemporaneous preparation and sterile preparation

(e.g. expiry date) shall be provided by knowledge database e.g.
Micromedex, Lexicom.
6.2.9.2. Stock availability of drugs by locations.
6.2.10. The decision support should be provided in the following work process of
medication function in CIS:-
6.2.10.1. Plan medication treatment.

6.2.10.2. Order medication.
6.2.10.3. Administer medication.
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6.2.10.4. Record medication.
6.2.10.5. Monitoring of Adverse Drug Reaction.
6.2.11. The decision support for clinical pharmacy should be provided in the
following:-
6.2.11.1.Monitor medication administration and reaction for specified

drugs.
6.2.11.2.Monitor medication administration and reaction for certain
condition.
6.2.11.3.Monitor medication administration for certain types of patients.
6.3. Drug Counselling:-
6.3.1. Drug counselling shall be made available at the point of care.

6.3.2. Counselling shall be provided in accordance to the care plans (individual/
group counselling).
6.3.3. Pharmacist shall be available for patient counselling.
6.3.4. Pharmacist shall counsel hospital registered patients as per request.
6.3.5. Documentation of external clients requesting counselling shall be done
manually.
6.3.6. Counselling materials i.e. drug leaflet, counselling guide and tools will be
determined by local policy but later should be standardized nationally.
6.3.7. Priority status of patient to be counselled shall be determined by
pharmacist according to patient’s needs.
6.3.8. All hospitals shall use Standard Counselling Medication Forms (individual
and group).
6.3.9. The standardized Medication Counselling Forms (individual and group)
template form shall be created by MOH.
6.4. Clinical Pharmacokinetic Services (CPS):-
6.4.1. Clinical Pharmacokinetic Services encompass Therapeutic Drug

Monitoring (TDM) and pharmacokinetic consultation.
6.4.2. Pharmacist shall have the privilege to place TDM order and relevant
blood test.
6.4.3. Pharmacist should have the privilege to view the result as soon as
possible.
6.4.4. Only pharmacist should interpret the TDM result.
6.5. Adverse Drug Reaction:-
6.5.1. All ADR cases shall be reported to pharmacist.

6.5.2. The required information format must be in accordance to the National
ADR format used by MOH.
6.5.3. Emphasis on monitoring of ADR should be on:-
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6.5.3.1. New drugs in hospital formulary.
6.5.3.2. Generic substitution.
6.5.3.3. Non- formulary drugs (the above criteria may change from time
to time).
6.5.3.4. Only doctors and pharmacist are authorized to fill ADR report
forms.
6.5.3.5. Pharmacist shall check and verify all completed forms before
sending to MADRAC.
6.5.3.6. Pharmacist shall disseminate ADR information within the
enterprise.
6.5.3.7. Pharmacist should disclose ADR findings in Drug Committee
Meetings in the facility.
6.6. Clinical Monitoring Medication:-
6.6.1. All hospitals shall use a Standard Medication Monitoring Form.

6.6.2. The Standard Medication Monitoring Form template shall be created by
MOH.
6.6.3. Reports shall be handled only by pharmacist.
6.7. Manufacturing:-
• All pharmacy personnel shall be trained appropriately according to their

job functions. There shall be sufficient personnel for efficient and effective
operational of the Manufacturing Pharmacy Unit.
• Pharmacist shall be in charge of manufacturing unit and shall be
responsible to ensure all products are manufactured in accordance with
Good Manufacturing Practice (GMP) and stored in accordance with Good
Storage Practice (GSP).
• Stock level shall be monitored and controlled by the pharmacist.
• “Ready to dispense” packs shall be made available when ever possible.
• Compounding of extemporaneous and manufacturing of galenical products
shall only be carried out if commercial products are not available.
• Supply of manufactured product can be made to other health facilities
that do not have manufacturing facilities.
• All finished products shall be approved by responsible pharmacist before
release to use.
• All quality control test (on products or environments) should be done if
necessary either using in-house or private Quality Control Laboratories.
• The validation, calibration and maintenance of equipment and clean
rooms shall be done by qualified service providers and shall be carried
out on a scheduled basis.
• Preparations and manufacturing records shall be maintained for a period
of 2 years from the date of production.
• All non-sterile preparations shall be performed in a controlled
environment.
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6.7.1. Pre-pack:-
6.7.1.1. Pharmacist shall be responsible for usage planning and indenting

of bulk medicine from Pharmacy Store.
6.7.1.2. Pharmacy Assistant shall be responsible for identification of
indented bulk medicine, inter unit pre-packing and maintaining
par level of pre-pack stock:-
6.7.1.2.1. The labels of pre-pack medication shall contain code

number, drug name, strength, quantity, expiry date,
and batch number.
6.7.1.2.2. The pre-pack medicine shall be checked and verified
by Pharmacy Assistant prior to storage.
6.7.1.2.3. Storage of the pre-pack medicine shall be according
to specifications of the manufacturer and sufficient
storage area shall be provided and arranged
accordingly for easy access.
6.7.1.2.4. Pharmacy Assistant shall determine par level of pre-
pack packages based on demand.
6.7.1.2.5. Pre-packing procedures work sheets shall be in
accordance with MOH guideline, documented and
stored in hard and soft copy.
6.7.2. Extemporaneous Preparations:-
6.7.2.1. All extemporaneous preparations must be in the MOH drug list.

6.7.2.2. Under certain circumstances, extemporaneous preparations not
in the MOH drug list can be prepared only if supported by stability
data.
6.7.3. Sterile Preparations:-
6.7.3.1. Aseptic Processing:-

• All aseptic processing activities shall be done under
appropriate clean room conditions.
• Aseptic technique procedures shall be handled by
trained and qualified personnel.
6.7.3.1.1. Eye Drops:-
6.7.3.1.1.1. Only approved eye drop formulation shall

be prepared.
6.7.3.1.1.2. All manufactured eye drops shall be
updated in the inventory and stock level
shall be monitored.
6.7.3.1.1.3. Eye drops preparation work sheets shall
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be in accordance with MOH guideline,
documented and stored in hard and soft
copy.
6.7.3.1.2. Parenteral Nutrition (PN) and Intravenous Admixture (IV

Ad):-
6.7.3.1.2.1. All components of PN preparation shall be

as listed in the MOH Drug List or special
approval should be obtained for non- MOH
Drug prior to procurement.
6.7.3.2. Cytotoxic Drug Reconstituition (CDR):-
6.7.3.2.1. All cytotoxic drugs shall be reconstituted by Pharmacy

Department.
6.7.3.2.2. CDR shall be conducted in appropriate clean room
facilities with due consideration given to personnel
and environmental protection.
6.7.3.2.3. Dispensing and disposal of hazardous material shall
be done appropriately.
7. HIGH LEVEL WORKFLOWS (depend upon scope of work in the hospital):-
7.1. Clinical Pharmacokinetic Services Workflow – PhIS/CP/WF/1.
7.2. Monitoring Medication Managements of In-Patients Workflow – PhIS/CP/WF/2.
7.3. ADR Monitoring & Reporting Workflow - PhIS/CP/WF/3.
7.4. Enquiries From Consumers & Healthcare Providers Workflow – PhIS/CP/WF/4.
7.5. Counselling for Outpatient and Inpatient (Individual & Group) Workflow – PhIS/
CP/WF/5.
7.6. Manufacturing Workflow:-
7.6.1. CDR/PN/IV AD & EYE DROP Workflow:-
7.6.1.1. Receiving Request Order For CDR/PN/IV Ad & Eye Drop –

Internal Client Workflow - PhIS/CP/WF/6.
7.6.1.2. Receiving Request Order For CDR / PN /IV Ad & Eye Drop –
External Client Workflow – PhIS/CP/WF/7.
7.6.1.3. PhIS/CP/WF/8 Aseptic Technique Compounding of Request
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Order For CDR/PN/IV Ad & Eye Drop Workflow – PhIS/CP/
WF/8.
7.6.1.4. Requesting & Receiving Prepared Medication For CDR/PN/IV

Ad & Eye Drop from Other Healthcare Facilities (Out Source)
Workflow – PhIS/CP/WF/9.
7.6.2. Pre-packing of Medicines Workflow – PhIS/CP/WF/10.
7.6.3. Preparation of Extemporaneous Product Workflow – PhIS/CP/WF/11.
7.6.4. Manufacturing of Galenical Preparations Workflow – PhIS/CP/WF/12.
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Clinical Pharmacokinetic Services Workflow
PhIS/CP/WF/1
CIS
Review patient
records selected for
TDM
(Doctor/Pharmacist)
Amend the order/

Place TDM order
place new order CIS
(Doctor/Pharmacist)
(Doctor/Pharmacist)
PhIS
Receive and
acknowledge TDM
Order
(Pharmacist)
Verify TDM order

(Pharmacist)
Discuss with
Discrepancy Yes prescriberr
detected? (Pharmacist)
No
Acknowledge verified CIS

Label Printing
order
(Doctor/Nurse)
Draw blood
sample
(Doctor/Nurse)
Acknowledge sample
sent to laboratory
(Nurse)
Send to laboratory
(Pneumatic Tube/
Nurse)
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A
View partial
result
(Doctor/
Pharmacist)
CIS
Intepret TDM
Decision support:
result
(Pharmacist) - Pharmacokinetic Software
Does drug/ No
dosage need
changes?
Yes
Discuss with
prescriber
(Pharmacist)
View final result

(Doctor)
Prepare new
drug/dosage
plan
(Doctor)
Record task &

document
findings
(Doctor/
Pharmacist)
END
Note: For external request for CPS , pharmacist shall transcribe the order into PhIS
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Monitoring Medication Managements of In - Patients Workflow
PhIS/CP/WF/2
IP
Medication
Registration
Retrieve medication order list

(Pharmacist)
Select patient with pre-

determined criteria
(Pharmacist)
Retrieve patient information

(Pharmacist)
Pharmacy Station
Decision support:
-To retrieve drug information
Patient list Choose appropriate patient -To download patient information and
(Pharmacist) pharmacist recommendation into
suitable portable devices
Counseling Counseling
Yes
required? Workflow
No
ADR
ADR detected? Yes
Workflow
No
Scheduling Appointment/
Yes
appointment? Schedule WF
Ward No
Discuss recommendation
(Pharmacist)
Update finding and record

Report task CIS/PhIS
(Doctor/Pharmacist)
End
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ADR Monitoring and Reporting Workflow
PhIS/CP/WF/3
CIS/PhIS
Include verbal report Received ADR

order / report
(Pharmacist)
Retrieve/review
information
(Pharmacist)
Investigate/refer back
Is clinical /product
No to prescriber
information complete?
(Pharmacist)
Yes
Transcribe Authenticate findings

report received
and update database CIS
from MADRAC
(Pharmacist)
Send report to MADRAC

and disseminate
information
(Pharmacist)
Report Record task &

document finding
End
This Workflow is applicable for suspected or reported cases of ADR )
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Enquiries From Consumers & Healthcare Providers Workflow
PhIS/CP/WF/4
CIS
Manual Enquiries Shall Include :

- walk-in
Receive enquiries - letters
(Pharmacist) - phone calls
Shall Include manual check and

verification
Check/verify and
document enquiries
(Pharmacist)
Shall Include manual search

- journals
Access knowledge - pharmacopoeia
databases - etc
(Pharmacist)
Shall include information provision by :

- calls
- letters
Provide information to - personal
enquirer - etc
(Pharmacist)
Drug information
Record task & document
record form
finding
End
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Counselling for Outpatient and Inpatient (Individual & Group) Workflow
PhIS/CP/WF/5
CIS PhIS
Counselling Counselling
Order Order
Order Filter by location Acknowledge

(Pharmacist)
Appointment needed Yes
No
Schedule
Retrieve patient record Scheduling
CIS appointment
(Pharmacist) Workflow
(Pharmacist)
Drug leaflet/
Counseling guide/ Prepare counseling
Drug monograph materials and information
(Pharmacist)
Record task and document

findings
(Pharmacist)
Counsel patient
(Pharmacist)
Record finding inform

Any medication Yes
care provider Yes
related problems?
(Pharmacist)
No

Report findings
(Pharmacist)
Is follow-up
Decision Support required?
- Non Compliance
- Chronic diseases
- Geriatrics No
- Multiple drug therapy
End Task
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Receiving Request Order For CDR/PN/IV Ad & Eye Drop - Internal Client Workflow
PhIS/CP/WF/6
CIS
Receive and
acknowledge order
(Pharmacist/
Pharmacy Assit.)
Decision Support:
Dosage
Calculation, Check and verify
Drug order
Allergy,Stability, (Pharmacist)
Adverse effect,
Compatibility,
Nutrient Calculation
Discuss requirement
Need further
Yes with care provider
clarification ?
(Pharmacist)
No
Decision Support:
Dosage Record task
Plan dosage schedule/ Does modification & modify
Calculation, No Any changes? Yes Yes
nutritional plan require new order? document
Drug
Allergy,Stability, (Pharmacist) (Pharmacist)
Adverse effect,
Compatibility, No
Record task & document Modify order

findings (Pharmacist)
(Pharmacist)
Record task &

Document
findings
Worksheet/label/ Generate worksheet (Pharmacist)
report(s) & labels
(Pharmacist)
CIS
Check the label against worksheet
(Pharmacist)
Is label correct No Reprint label Label
Yes
PhIS/CP/
WF/8
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Receiving Request Order For CDR / PN / IV Ad & Eye Drop - External Client Workflow
PhIS/CP/WF/7
start
Receive order
Assist .)
Verify order
(Pharmacist)
Discuss with care Inform care provider

Require (Pharmacist)
Yes provider
clarification?
(Pharmacist)
No Yes
Make order entry No Is modification Requires new

Yes
(Pharmacist) required? order?
Decision Support: Plan dosage

Dosage Calculation, schedule/nutritional
Drug Allergy,Stability , No
plan
Adverse effect, (Pharmacist)
Compatibility,
Record task &

document findings
(Pharmacist)
Generate
Worksheet/Label/
worksheet
report(s)
& labels
(Pharmacist)
Check the label against

worksheet
(Pharmacist)
Reprint label Label

Is Label correct? No
(Pharmacist)
Yes
PhIS/CP/
WF/8
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Aseptic Technique Compounding of Request Order For CDR/PN/IV Ad & Eye Drop
Workflow
PhIS/CP/WF/8
PhIS/CP/WF/6
&
PhIS/CP/WF/7
Prepare required components

(Pharmacist/Pharmacy Assist.)
No Counter check components

Is component correct?
Yes
Prepare clean room
Compounding medication
Check products against

worksheet
Reject & Record task &

Analyse cause document findings
Is product correct ? No (Pharmacist/
of rejection
(Pharmacist) Pharmacy Assist.)
Yes
Label container
Reprint label Yes Is label damage?
No
Quarantine for verification No

Label (Pharmacist)
Is product approve ?
Yes
Release to Manufacturing Unit

storage
Supply to Requesting Unit

Assist .)
Record Task & Document

Findings
Assist .)
End
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Requesting & Receiving Prepared Medication For CDR/PN/IV Ad & Eye Drop from Other
Healthcare Facilities (Out Source) Workflow
PhIS/CP/WF/9
CIS No
Decision Support:
Dosage Calculation, Receive and
drug allergy, stability, acknowledge order
adverse effect, (Pharmacist/Pharmacy
compatibility Assit .)
Check and verify order

(Pharmacist)
Discuss requirement
Need further Yes with care provider
clarification ?
(Pharmacist)
No
Plan dosage schedule/ Record task &

nutritional plan No Does modification modify
Any changes? Yes Yes
(Pharmacist) required new order? document
Decision Support: (Pharmacist)
Dosage Calculation,
drug allergy, stability , No
adverse effect, Generate requesf form
compatibility (Pharmacist)
Nutrient Calculation Modify order
(Pharmacist)
Request form Print request form

(Pharmacist)
Record task &

document findings
Inform other healthcare facility (Pharmacist)
(Pharmacist)
Send request form and make

appointment for collection
(Pharmacist/Pharmacy Assist )
Collect prepared medication

Acknowledge received
prepared medication
Assist)
Store in Manufacturing Unit

Supply to request unit

Assist)
Record task & document

findings
Assist)
End
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Pre-packing of Medicine Workflow
PhIS/CP/WF/10
Start
Check physical stock

(Pharmacy Assist)
Retrieve pre-pack list that

requires replenishment
(Pharmacist/Pharmacy Asst)
Work sheet Prepare and print work sheet

Issue bulk medication

(Pharmacy Asst)
Generate and print product

label Label
Re-print label
Is product label
No (Pharmacy Asst/
correct?
Attendant)
Yes
Label the envelope/container

(Pharmacy Asst/ Attendant)
Is label damaged ? Yes
No
Pack product
(Pharmacy Asst./ Attendant)
Store product
(Pharmacy Asst.)
Update pre-pack stock

inventory
(Pharmacy Asst.)

finding Report
(Pharmacist/ Pharmacy Asst.)
End
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Preparation of Extemporaneous Product Workflow
PhIS/CP/WF/11
This high level flow is applicable for DD and non-DD
PhIS –
extemporaneous. DD extemporaneous shall be compounded by
OP/IP
Pharmacist in accordance to DD Act.
Receive order
(Pharmacist Assist.)
Refer to Pharmacist
Is it a DD? Yes
(Pharmacy Assist)
No
Prepare and print work Prepare and print work

Work sheet Work sheet
sheet sheet
(Pharmacist Assit .) (Pharmacist)
Check worksheet
(Pharmacist/Pharmacy Assist) No Check worksheet
No
(Pharmacist)
Is product correct ? Is product

Correct?
Yes Yes
Generate label Generate label

Label (Pharmacist/Pharmacy (Pharmacist)
Assist)
Prepare material Prepare material

(Pharmacist/Pharmacy Assist) (Pharmacist)
No No
Counter check material/label Counter check material/ label
Correct? Correct?
Yes Yes
Prepare and compound Prepare and compound

product product
(Pharmacist/Pharmacy Assist ) (Pharmacist)
Pack and label the product Pack and label the product
Record task and

Record task and
Report document findings Report
document findings
(Pharmacist)
Assist )
Supply PhIS Supply

(Pharmacist/Pharmacy Assist) IP/ OP (Pharmacist)
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Manufacturing of Galenical Preparations Workflow
PhIS/CP/WF/12
Start
Check physical stock

(Pharmacy Assist)
Retrieve preparation list

(Pharmacist/ Pharmacy
Work sheet Asst.)
Prepare and print work

sheet
Asst.)
Measure/ weigh material

(Pharmacy Asst.)
No
Counter check material

(Pharmacist)
Is material correct?
Yes
Prepare product
Counter check product

Record Task &
Reject & analyse
Is product ok ? Document Findings
No cause of rejection
(Pharmacist/
(Pharmacist)
Pre packing Yes Pharmacist Assist .)
workflow Need for pre packing
Yes
PhIS/CP/
WF/10
No
Generate and print bulk
Label products label
Asst.)
Pack and label the bulk product

(Pharmacy Asst./Attendant) No
Is finished product ok?
Yes
Quarantine for verification
(Pharmacist)
Is it approve for use?

Yes
Store and supply finished product

Record task & document findings

End
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MAPPING OF THE WORK PROCESS/SYSTEM
FUNCTIONALITIES AND OPERATIONAL POLICIES 8
Clinical Pharmacokinetic Services - PhIS/CP/WF/1
1. Review patient • Ability to view patient’s record. • Pharmacist shall have

record selected access CIS however
for TDM. • Ability to view TDM information (e.g. any recommendation
sampling guideline). or intervention in
the PhIS should be
integrated in the CIS.
2. Place TDM order. • Ability to place TDM order. • Pharmacist shall

have the privilege to
• Ability to schedule blood sampling place TDM order and
time according to drug database and relevant blood test.
individual drug requested.
3. Receive and • Ability to receive online TDM order. • Pharmacist shall be

acknowledge TDM The system shall able to display the authorised to receive
order. list of the order. and acknowledge TDM
orders.
• Ability to alert incoming order.
• Ability to capture date, time, name transcribed all external
of pharmacist who acknowledge and TDM request.
verify the orders.
• Ability to transcribe all external TDM

request.
4. Verify TDM order. • Ability to verify TDM order. • Pharmacist shall be

authorised to verify
• Ability to audit trail all TDM orders TDM orders.
received.
• Ability to link and access drug

information database.
5. Amend the order • Ability to amend/cancel TDM order. • Pharmacist shall be

/place new order. authorised to amend/
• Ability to place new order. cancel and place new
TDM order.
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• Ability to do audit trail.
6. Acknowledge • Ability to acknowledge order which • Prescriber and nurse

verified order. had been verified by pharmacist. shall be authorised
to acknowledge the
• Ability to enter data for actual time verified order.
and date blood sample taken from
patient.
7. Acknowledge • Ability to acknowledge sample which • All samples sent to

sample sent to had been sent to laboratory. laboratory shall be
laboratory. acknowledged.
8. View partial TDM • Ability to inform the prescriber • Prescriber and

result. /pharmacist to review the partial pharmacist shall be
result (without interpretation by authorised to view the
pharmacist). partial result.
• Ability to alert drugs which are sub-

therapeutic or toxic level.
• Ability to close the partial result after

the result has been interpreted by
pharmacist.
• Ability to view the previous last two

TDM results within six months from
the latest date.
9. Interpret TDM • Ability to calculate the suggested • Only pharmacist

result. dose based on the laboratory result. should interpret the
result.
• Ability to interface the result from LIS
to Pharmacokinetic Software.
10. View final result. • Ability to inform the doctor to review

completed result which had been
interpreted by pharmacist.
11. Record task • Ability to do audit trail - person login,

and document time and date of recommendation.
findings.
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• Ability to print weekly, monthly

and yearly statistics (graph) and
summary reports base on.
• Number of interpretations done.
• Number of recommendation
accepted by prescriber.
• Number of toxicity and patient

categories.
• Number of interpretation made within

2 hours (for toxic levels).
• Number of interpretation made within

24 hours (for normal levels).
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Monitoring Medication Managements of In-Patients – PhIS/CP/WF/2.
1. Retrieve • The system shall be able to display • The pharmacist

medication order and print relevant demographic shall access the
list. information and should include CIS to convey to the
outstanding tasks related to the attending doctor any
following:- recommendation or
o PN. intervention.
o Clinical Pharmacokinetic Services.
o CDR. • Emphasis on
o IV AD. monitoring of ADR
o Counselling. should be on:-
o ADR. o new drugs in
o Medication Related Problems. hospital formulary.
o generic substitution.
• The system shall be able to link any o non- formulary
orders made and to be displayed drugs.
as outstanding, once the orders are
submitted by the doctor.
• The system should be able to

convert the status of the order as
“completed” once the task(s) has
been carried out.
2. Select patient • The system shall be able to display • All pharmacists

with pre- and print relevant demographic will have access to
determined information and should include CIS. However any
criteria. outstanding tasks related to the recommendation
following:- or intervention in
o PN. the PhIS should be
o TDM. integrated in the CIS.
o CDR.
o IV AD.
o Counselling.
o ADR.
o Medication Related Problems.
3. Retrieve patient • The system shall be able to display • The chronological

information. any latest / updated episode order of episode
summary in the system. summary by default
shall be determined by
• The system should provide search local policy.
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functionality by location, patient’s

particulars, episodes, date of
admission or others, to view episode
summary.
4. Choose • The system shall be able to indicate • The wards shall

appropriate and print the list of selected patients. be provided with a
patient. common workstation
• The system shall be able to transmit to be used by health
any updates by pharmacist into professionals such as
suitable portable devices (this is pharmacist, dieticians,
based on the assumption that all therapists and
pharmacist doing the medication counsellors.
monitoring are to have a suitable
portable device).
• The main system should be able to

capture information from the palm
top/suitable portable devices and
make necessary update in the main
system.
5. Schedule • Enable authorized user to schedule • Hospital shall update

appointment. appointment in Scheduling module the pharmacist list to
(HIS). provide medication
monitoring.
• Ability to schedule appointment by
location, discipline, priority status
and by pharmacist name and
availability.
6. Update findings • Ability to update any findings • All hospitals shall use
and record task. relevant to medication monitoring. a Standard Medication
Monitoring Form.
• Ability to do audit trail - person login,
time and date of recommendation. • The Standard
Medication Monitoring
• Ability to support textual information Form template shall be
up to 2000 words during medication created by MOH.
monitoring.
• The system shall support a standard
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medication monitoring format with

pre determined data elements.
7. Statistical report. • The system shall be able to generate • Reports shall be

statistical reports with the following handled only by
data:- pharmacist.
o Pharmacist intervention.
o Time and date of intervention.
o Person who intervened.
o Number of rounds.
o Pharmacy rounds.
o Follow-up cases.
o Types of interventions.
• Ability to view and print the required

report.
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Adverse Drug Reaction (ADR) Monitoring and Reporting-PhIS/CP/WF/3
1. Received ADR • Ability to alert the pharmacist on • All ADR cases shall be
order/report. ADR incidences within enterprise. reported to pharmacist.
2. Retrieve/review • Ability to retrieve and review the • The required

information. required information. information format
must be in accordance
• Ability to access to ADR form in a to the National ADR
user friendly and quick access. format used by MOH.
• All medical staffs are

allowed access to and
fill ADR form.
• Emphasis on
monitoring of ADR
should be on:-
o new drugs in hospital
formulary.
o generic substitution.
o non- formulary drugs.
3. Investigate/refer • Ability to update ADR findings into • The responsible

back to healthcare CIS. pharmacist shall
providers. investigate all ADR
• Ability for doctor to rectify and cases.
complete report.
• Pharmacist shall have
• Ability for to amend and cancel ADR access to CIS for
report. investigation.
• Ability to send back complete report • Pharmacist shall relay

to pharmacist. findings to doctors.
• Ability to indicate amended or new • Only the reporters

ADR report. are allowed to make
amendments or to
cancel ADR report.
4. Authenticate • Ability to create mandatory response • Only doctors and

findings and field based on the information which pharmacist are
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update database. will be determined by MADRAC. authorised to report

ADR.
• Ability to enter incomplete
information. • Pharmacist shall
check and verify all
• Ability to provide an ADR registry. completed forms
before sending to
• Ability to generate database MADRAC.
containing:-
o Date. • All the filled forms
o Reference number. should be sent directly
o Reporter. via the system to
o Drug name. MADRAC through the
o Summary of adverse drug reaction. pharmacy department.
o Classification of causality (certain,
probable, possible, unlikely,
unclassifiable) entered by reporter.
• Ability to transcribe report received

from MADRAC containing.
Classification of causality (certain,
probable, possible, unlikely,
unclassifiable) and MADRAC report
number.
5. Send report to • Ability to send ADR report online to • Pharmacist shall

MADRAC and MADRAC. disseminate ADR
disseminate information within the
information. • Ability to share the information of enterprise.
ADR report through the system
within enterprise. • Pharmacist should
disclose ADR findings
• Ability to disseminate information in Drug Committee
received from MADRAC. Meetings in the facility.
6. Record task • Ability to provide summary/list of

and document statistics based on the following:-
findings. o Number and types of ADR and
name of drugs to be displayed and
sorted according to month/year.
o Number / type of healthcare
providers reporting ADR reports
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o Number of pharmacists reporting

ADR reports.
• Ability to send filled forms through

website. Able to sort suspected
drugs which cause ADR including
information such as manufacturer,
batch number and registration
number.
• Ability to do audit trail - person login,

time and date of ADR reported.
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Enquiries from Consumers and Healthcare Providers-PhIS/CP/WF/4.
1. Receive enquiries • The system shall be able to capture • All medical staff are
calls/e-mails/ the following information:- allowed access to
walk-in/system o Priority. the system to make
activated. o Category of enquiries (poisoning, enquiries.
interaction, dose, ADR etc.).
o Category of enquirer (healthcare • The required
providers, consumers etc.). information format
o Enquirer particulars (name, must be in accordance
address, phone number etc.). with the standard
o Receiving and reply Date and format used by MOH.
Time.
o Response time. • Drug information
o Receiving personnel. for consumers and
o Responding personnel. healthcare providers
o Request summary. shall be provided
o Receive and reply mode by at each hospital
verbal, e-mail, telephone, fax or depending on hospital
letter. service level.
o Purpose of enquiries.
o References used. • If more information is
required, a higher level
reference centre shall
be consulted (such as
National DIC/Tertiary
Level DIC).
• All Drug Information

Enquiries (Internal &
External Client) shall
be attended to.
2. Check/verify • Ability to generate task list and • The pharmacist shall

and document provide alert on incoming enquiries. be responsible for
enquiries. checking and verifying
• Ability to categorize enquiries all enquiries.
according to pre-determined criteria
and generate report.
• Ability to provide status of enquiries
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3. Access knowledge • Ability to access an internal and • The hospital shall

database. external knowledge database. make available
knowledge databases
according to the
requirement of
hospitals.
allowed access to
subscribed electronic
databases at MOH
level.
4. Provide • Ability to provide information at the • Pharmacist shall be

information to point of care. responsible to provide
enquirer. information searched
from knowledge
database.
5. Record task & • Ability to do audit trail - person login, • Pharmacist shall
document finding. time of query and response time. be responsible to
maintain, record task
• Ability to transcribe into the system and document finding.
enquiries received and recorded
manually.
• Ability to generate summary of

queries, answers and responses
transaction for the specified period.
• Ability to generate frequently asked

question.
Details of the query should be based
on the following:-
o Priority.
o Category of enquiries (poisoning,
interaction, dose, ADR etc.).
o Category of enquirer (healthcare
providers, consumers etc.).
o Enquirer particulars (name,
address, phone number etc.).
o Receiving and reply Date and
Time.
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o Response time.
o Receiving personnel.
o Responding personnel.
o Request summary.
o Receive and reply mode by
verbal, e-mail, telephone, fax or
letter.
o Purpose of enquiries.
o Reference used.
• Ability to view and print the required

report.
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Counselling for Outpatient & Inpatient (Individual & Group)-PhIS/CP/WF/5
1. PhIS counselling • Ability to display and filter patient • Pharmacist shall be

order. by location and priority based on available for patient
medications and disease conditions. counselling.
• Ability to alert for any outstanding • Only pharmacist

counselling by clinical care setting or shall have access
by patient. to counselling
applications.
• Ability to receive counselling orders
from all location. • Pharmacist shall
counsel hospital
registered patients as
per request.
• Documentation
of external clients
requesting counselling
shall be done manually.
2. Acknowledge • Ability to create and acknowledge

counselling task counselling task list by day,
list. date, time, location and name of
pharmacist.
• Ability to track counselling order

status by received, pending and
completed.
3. Retrieve patient • Ability to retrieve the following • Only pharmacist shall

information. patient’s details as per CIS/PMS/ be authorised to view
LIS such as patient demography, and document the
social history, medication history & medication counselling
diagnosis, drug allergies, pregnancy records.
and lactation, lab results.
4. Prepare • System shall be able to allow • Authorised personnel

counselling pharmacist to access relevant shall have access to
materials and knowledge databases. counselling materials.
information.
• Ability to print information such as:- • Counselling materials
o Drug Information. i.e. drug leaflet,
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o Adverse Drug Reaction. counselling guide will

o Special Instructions. be determined by
o Interactions. local policy but later
o Pharmacokinetics. should be standardised
o Storage. by National Drug
Information Centre/
Patient Counselling
Committee MOH.
5. Record task & • Ability to indicate order status in CIS • Only authorised
document finding. for medication counselling. personnel shall be
allowed to record task.
• Ability to generate a template for
recording medication counselling to
include structured and textual data.
• All documentation of counselling

must include the following:-
o Compliance status.
o ADR.
o Allergy.
o Drug Interaction.
o Alternative medicine.
6. Schedule • Enable authorized user to schedule • Hospital shall update

appointment. appointment in Scheduling module the pharmacist list to
(Patient Management System). provide counselling.
• Ability to schedule appointment by • Appointment for follow

location, discipline, priority status up counselling shall
and by pharmacist name and be determined by
availability. pharmacist.
7. Print report and • Ability to generate and print statistic • Only authorised
record tasks and reports as required by MOH through personnel shall be
finding. appropriately designed query tools. allowed to access the
statistics and reports.
• Ability to create user defined format
of reporting when necessary.
• Ability to provide textual information

(up to 2000 words) during
medication counselling.
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• The system shall support a • All hospitals shall use

standard counselling format with pre Standard Counselling
determined data elements. Medication Forms
(individual and group).
• The standardised
Medication
Counselling Forms
(individual and group)
template form shall be
created by MOH.
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Receiving Request Order For CDR/PN/IV Ad & Eye Drop - Internal Client PhIS/CP/WF/6
Receiving Request Order For CDR / PN /IV Ad & Eye Drop - External Client PhIS/CP/WF/7
Aseptic Technique Compounding of Request Order For CDR/PN/IV Ad & Eye Drop
PhIS/CP/WF/8.
1. Receive, • Ability to receive order from all • Receive and

acknowledge and clinical settings. acknowledge orders
transcribe order. can be done by
• The system shall be able to display pharmacy assistant.
the list of orders with status (new
order, continuous order) and name • Pharmacy assistant
of hospital/healthcare facilities where can view patients’
the order comes from. record - patient’s
name, MRN, age, body
• Ability to capture date, time, name weight, BSA (Body
of pharmacy personnel who receive Surface Area), BMI
and acknowledge orders. (Body Mass Index),
demographic, doctor’s
• The ability to trigger automatic order name.
for the continuous order.
• List of preparations
• Ability to route of all orders to shall be governed by
respective preparing unit. MOH policy.
• Only complete orders

from other healthcare
facilities shall be
processed.
• Make order entry,

check and verify order
from other healthcare
facilities shall be done
by pharmacist only.
2. Check and verify • The ability to view patient’s • Pharmacist can view
order. record patient’s name, RN, age, patient’s record -
body weight, BSA (Body Surface patient’s name, RN,
Area), BMI (body mass index), age, body weight,
demographic, diagnosis, allergies, BSA (Body Surface
relevant lab results, prescriber’s Area), BMI (body mass
name. index), demographic,
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• Ability to capture date, time, name diagnosis, allergies,

of pharmacy personnel involved in relevant lab results,
checking and verifying orders. doctor’s name.
• Ability to nullify the orders upon • Only pharmacist shall

patients’ discharge, death or when be allowed to verify
treatment is discontinued. order.
• Only authorised
personnel are allowed
to nullify orders.
3. Modify order. • Ability to edit & update any dosage • Only pharmacist is
changes. authorised to edit &
update changes.
• Ability to capture all modifications
made into patient’s record.
4. Plan dosage • Ability to link and access drug • Only pharmacist is

schedule/ information database such as drug authorised to plan
nutritional plan. interaction, incompatibility and dosage schedule/
dosage. nutritional plan.
• The ability to alert when:-

o The dosage is not within the range
based on body weight or body
surface area (for CDR).
o Incompatibility with other drugs or
diluents based on the establish
database or reliable drug
resources.
• Ability to integrate with Pharmacy

Store inventory to determine the
availability of the drugs.
5. Generate • Ability to create, view and print/ • Only Pharmacist is

worksheet reprint pre-defined CDR/IV AD authorised to make
& labels. (including care sets) and PN changes on the
worksheet. worksheet. Pharmacy
Assistant can only view
• Ability to auto calculate the total the worksheet.
number of vials/ampoules/volumes
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of solutions to be used based on the • Work sheets of

dosages prescribed for all the patient preparations shall
with an ability to manually override be documented and
recommended calculation. maintained in hard and
soft copy.
• Ability to capture the quantity of
the materials/drugs used for all the • Label sample shall
preparation done. be pasted to the
worksheet.
• Ability to capture quantity and type of
spillages.
• Ability to generate, view and print/

reprint label according to different
type of preparations.
• Ability to generate labels whenever

required with the following
components:-
o PN:-
• Name of patient.
• Patient Identification.
• Ward/Clinic/Room No/Bed No.
• Healthcare Facilities.
• Date and time of manufacture.
• Date and Time of expiry.
• Infusion rate.
• Electrolyte Content.
• Trace Element.
• Vitamin
• Lipid Content.
• Dextrose, amino acid, glucose
content.
• Infusion Rate.
• Total Volume/Bag.
• Total Calorie/Bag.
• Storage Condition.
• Cautionary label.
• Prepared by:
• Checked by:
• Product No:
o CDR:-
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• Patient ID.
• Healthcare Facilities.
• Drug Name.
• Strength.
• Volume.
• Frequency.
• Diluents.
• Reconstitute Date and time.
• Prepared by:
• Checked by:
• Product No:
o IV Ad:-
• Patient Identification.
• Healthcare Facilities Name.
• Name of Product.
• Strength.
• Volume.
• Frequency.
• Date and time of compounding.
• Prepared by:
• Checked by:
• Product No:
• Ability to reprint label when required.
6. Quarantine for • Ability to show and adjust to the • All finished products
verification. current status of the finished products shall be verified
as rejected, quarantine, released. and approved by
responsible pharmacist
• Ability to change status of the before release.
preparation only by the responsible
pharmacist. • The responsible
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pharmacist shall not

be the person who
is involved in the
preparation of the
product.
7. Stage of process. • Ability to document the stage of

process (from order to completion).
8. Supply to • Ability to identify the collection date, • All finished products

requesting unit. time and identity of the collectors. shall be collected from
manufacturing store
and within specified
date.
9. Record task • Ability to record and document the • Only pharmacist is

& document followings:- authorized to record
findings. o Any dosage changes, counter and document findings
check of materials/ingredient on dosage changes,
used, counter check of label counter check of
pasted on product. materials/ingredient
used, counter check
• Ability to do audit trail for any of label pasted on
changes and/or process. product.
• Ability to indicate the preparation of • Pharmacy assistant

the product is complete and captures can record task and
time of completion. document findings for
collection of finished
product and capture
any spillages/extra
materials during
reconstitution.
10. Reporting. • Ability to generate, view and print

daily, weekly, monthly, quarterly and
yearly workload reports.
• Statistics (graph) and summary

reports based on:-
o Location, prescriber, drug, dose
(CDR), No of patients, PN bags for
paediatrics and adult preparation,
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quantity of materials used.
• Ability to report any spillages during

reconstitution of cytotoxic drugs.
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Requesting & Receiving Compounded Medication for CDR//PN/IV Ad from Other Healthcare
Facilities (Out Source) – PhIS/CP/WF/9.
1. Receive & • The ability to receive order within the • Receive and
acknowledge hospital and from other healthcare acknowledge orders
order. facilities. The system shall be able to can be done by
display the list of orders with status pharmacy assistant.
(New order, continuous order) and
name of hospital/healthcare facilities • Pharmacy assistant can
where the order comes from. view patients record
- patient’s name, MRN,
• Ability to capture date, time, name age, body weight, BSA
of pharmacy personnel who receive (Body Surface Area),
and acknowledge orders. BMI (Body Mass Index),
demographic, doctor’s
• The ability to trigger automatic order name.
for the continuous order.
• Preparation of orders
• Ability to route all orders to will be guided by local
respective preparing unit. policy.
• Ability to register orders from other • Only complete orders

healthcare facilities at point of care. from other healthcare
facilities shall be
processed.
2. Check and verify • The ability to view patient’s • Pharmacist can view
order. record - patient’s name, RN, age, patient’s record -
body weight, BSA (Body Surface patient’s name, RN,
Area), BMI (body mass index), age, body weight,
demographic, diagnosis, allergies, BSA (Body Surface
relevant lab results, prescriber’s Area), BMI (body mass
name. index), demographic,
diagnosis, allergies,
• Ability to capture date, time, name of relevant lab results,
pharmacy personnel who checked doctor’s name.
and verified orders.
• Only pharmacist shall
• Ability to nullify the orders upon be allowed to verify
patients’ discharge, death or when order.
treatment is discontinued.
• Only authorised
personnel are allowed
to nullify orders.
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3. Plan dosage • Ability to link and access drug • Only Pharmacist is

schedule/ information database such as drug authorised to plan
nutritional plan. interaction, incompatibility and dosage schedule/
dosage. nutritional plan.
• The ability to alert when:-

- The dosage is not within the range
based on body weight or body
surface area (for CDR).
- Incompatibility with other drugs or
diluents based on the established
database or reliable drug
resources.

Store inventory to determine the
availability of the drugs.
4. Modify order. • Ability to edit & update any dosage • Only pharmacist is
changes. authorised to edit &
update changes.
• Ability to capture all modifications
made into patient’s record.
5. Prepare request • Ability to generate request form • Only pharmacist is

form. according to the order made by authorised to prepare
doctor. request order.
• All request orders shall

be counter checked
prior to being sent to
other healthcare facility.
6. Print request form. • Ability to view and print request form.
• Ability to reprint request form when

ever necessary.
7. Inform healthcare • Only pharmacist

facility involved. shall be allowed to
communicate with
other healthcare facility
involved.
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8. Collect • Only authorised

compounded personnel shall
medication. allowed to collect
prepared medication.
• All prepared
medication shall
be handled in a
proper way during
transportation.
9. Acknowledge • Ability to capture date, time and

receipt of personnel who received the
compounded prepared medication.
medication.
• Ability to show and update the status
of order as pending or complete.
10. Supply to • Ability to identify the collection date, • All finished products
requesting unit. time and identity of the collectors. shall be collected from
Manufacturing Unit
and within specified
date.
11. Record task • Ability to record and document the

and document followings:-
findings. o any dosage changes.
• Ability to do audit trail for any

changes and/or process.
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Pre-Packing of Medicine – PhIS/CP/WF/10.
1. Retrieve pre-pack • Ability to retrieve, display and print • Only authorised

list that requires list of low-level pre-packed items. personnel are allowed
replenishment. to access PhIS.
responsible for usage
planning and indenting
of bulk medicine from
Pharmacy Store.
• Pharmacy Assistant
shall ensure the
continuous supply of
pre packed items for
dispensing.
2. Prepare and print • Ability to generate a work sheet. • Work sheets of pre-
work sheet. packed items shall
• Ability to allow free text to enter be documented and
comment/remarks in worksheet. maintained in hard and
soft copy.
• Ability to print a work sheet.
• Worksheet format shall
contain the relevant
information required for
traceability.
3. Issue bulk • Ability to integrate with Pharmacy • Issued bulk medication

medication. Store and Sub-Store inventory to for pre packing shall be
determine the availability of the checked and verified.
drugs used.
4. Generate and • Ability to generate and print label. • Label sample shall
print product label. The label shall contain the following:- be pasted to the
o Name of medication. worksheet.
o Strength of medication.
o Volume/ weight/ quantity of • All prepared labels
individual pack. shall be secured.
o Expiry date.
o Date Packing. • Reconciliation of labels
o Packing Batch Number. shall be recorded and
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o Manufacturer Name. discrepancies shall

o The phrase ‘Ubat Terkawal’. be investigated and
reported.
5. Pack product. • The pre-pack medicine

shall be checked and
verified by Pharmacy
Assistant prior to
storage.
• Quantity of pre
packed items shall be
reconciled with labels.
• Only one batch shall

be packed at any one
time.
• Preparation from
different batches shall
not be pre packed
together.
• Production line
clearance shall be
practised.
6. Reprint label. • Ability to reprint product label if

required.
7. Store product. • Storage of the pre-

pack medicine will
be according to
specifications of the
manufacturer.
8. Update pre-pack • Ability to update pre-pack stock • Only authorised

stock inventory. inventory. personnel is allowed to
update the pre packed
• Ability to enter name of staff. stock inventory.
• Distribution of finished
products shall follow
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EEFO and FIFO basis.
9. Record task and • Ability to generate and print report

document finding. based on MOH requirement.
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Preparation of Extemporaneous Product–PhIS/CP/WF/11.
1. Receive order. • Ability to display order from • Only authorised

requesting unit. personnel are allowed
to access PhIS.
• Ability to identify type of drug (DD
and non-DD products). • All extemporaneous
preparations must be in
the MOH drug list.
• All extemporaneous
preparations shall
follow Standard
Operating Procedure.
• Extemporaneous
preparations shall
be prepared only if
supported by stability
data.
2. Refer to • DD for
pharmacist. extemporaneous
preparation shall
be issued out by
registered pharmacist.
3. Prepare and print • Ability to generate and print work • Only responsible
work sheet. sheet. Work sheet shall contain:- pharmacist shall be
o Volume manufactured. allowed to update
o List of all ingredients in the extemporaneous
formulation and weight required. formulations database.
o Name of person who prepared and
counter checked the preparation.
• Ability to auto calculate the weight

of ingredients, based on the total
volume manufactured.
• Ability to create template for

structured and textual data entry.
• Ability to display worksheet print

preview.
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• Ability to maintain and update

extemporaneous formulation
database.
4. Generate label. • Ability to generate and print label.

The label shall contain the following:-
o Patient’s name.
o Drug name.
o Drug strength, dosage, frequency.
o Lot number.
o Preparation date.
o Expiry date.
o Storage condition.
o The phrase ‘Ubat Terkawal’.
5. Record task • Ability to generate and print report as • Record to be

and document per MOH requirement. maintained in the
findings. system for 2 years from
• Ability to purge/delete completed the date of expiry date
worksheet. and can be purged/
deleted thereafter.
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Manufacturing of Galenical Preparations - PhIS/CP/WF/12.
1. Retrieve • Ability to retrieve the list of • Only authorised

preparation list. preparations. personnel are allowed
to access PhIS.
• Ability to enter new formulary
preparations.
2. Prepare and print • Ability to generate and print work • Only responsible
work sheet. sheet. Work sheet shall contain:- pharmacist shall be
o Volume manufactured. allowed to update
o List of all ingredients in the galenical products
formulation and weight required. formulations database.
o Name of person who prepare and
counter check the preparation.
• Ability to calculate the weight of

ingredients, based on the total
volume manufactured.

Store and Sub-Store inventory
to determine the availability of
the drugs/ingredients used for
preparation and update the inventory
accordingly.
• Ability to maintain formulation

manufacturing database for galenical
products.
3. Counter check • All materials should

material. be counter checked
by another pharmacy
personnel before
preparation.
4. Generate and • Ability to generate and print label.

print bulk products The label shall contain the following:-
label. o Name of medication.
o Strength of medication.
o Volume of weight of individual
pack.
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o Manufacturing date.
o Expiry date.
o Batch No.
o Storage conditions.
5. Quarantine for • Ability to track the order status of • All finished products
verification. the finished products as rejected, shall be verified
quarantine, released. and approved by
responsible pharmacist
• Ability to deny access to change before release.
status by personnel other than the
responsible pharmacist. • The responsible
pharmacist shall not
• Ability to calculate and generate be the person who
report on percentage of yield. is involved in the
preparation of the
• Ability to add free text for product.
investigation report.
• Percentage of yield
shall be in the range
95-100%, otherwise
discrepancy shall
be investigated and
reported.
6. Store and supply • Ability to view list of finished • Distribution of finished

finished products. products and expiry date according products shall follow
to chronological orders/reverse EEFO & FIFO basis.
chronological orders.
• Ability to issue the near expired

finished products first.
7. Record task and • Ability to update inventory. • Record to be

document finding. maintained in the
• Ability to do audit trail of identity of system for 2 years from
person involved in the manufacturing the date of expiry date
of the product. and can be archived.
• Ability to generate and print a report

as per MOH requirement.
• Ability to generate list of items to
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be condemned in the specified

template.
• Ability to generate report of slow

moving and near expiry date stock
based on specified duration of time.
• Ability to enter free text for

comments e.g. any possible remarks
during counter check of material.
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ASSUMPTIONS 9
9.1. Drug Information will be made available in both CIS and PhIS.
9.2. Malaysian Drug Database shall be used as decision support for Drug Information
function.
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10 GLOSSARY
No Terms Definition
1. Clean room. Special preparation room according to GMP standard.
2. Continuous order. Same order that has made before with no changes.
3. Cytotoxic Drug Refers to reconstitution of toxic compounds that are

Reconstitution (CDR). carcinogenic, mutagenic, and/or has teratogenic potential
(refer to drugs only).
4. Dosage Schedule/ Regimes that are suggested by Pharmacist.

Nutritional Plan.
5. Extemporaneous A compounded, reconstituted or diluted preparation,

Preparation. freshly prepared due to instability of the compound.
6. Extemporaneous non- Refers to compounded preparations for local applications.

sterile external.
7. Extemporaneous non- Refers to compounded preparations to be consumed orally

sterile internal. by the patients.
8. Good Manufacturing A set of standard guidelines to ensure that products are

Practice (GMP). consistently produced and controlled by the quality standards
appropriate to their intended use and as required by the
marketing authorization or product specification.
9. Good Storage Practice The special measure that needs to be considered in the
(GSP). storage, transportation and distribution of products, such that
the product will be of the nature and quality intended when it
reaches the consumer.
10. Internal clients. Clients in the hospital only.
11. IV Admixture Service. Refers to compounding of an active ingredient with a

compatible diluent to form a ready to use preparation.
12. Other healthcare facilities. Outside the hospital.
13. Parenteral Nutrition (PN). Complete form of nutrition, containing protein, sugar, fat and
added vitamins, minerals and trace elements which are given
through parenteral route to the patient with conditions where
enteral nutrition is not tolerated, insufficient or likely lead to
complication.
14. Production line clearance. Completion of the pre-packing process for any one type and
batch of medicine.
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15. Quality Control Test. Recommended tests that shall be carried out for galenical
preparations to ensure that product manufactured is safe and
efficacious.
16. Tertiary Level DIC. Drug Information Centre at higher level (National, University,
State Hospitals).
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11 ABBREVIATIONS
No Terms Definition
1. ADR. Adverse Drug Reaction.

2. BMI. Body Mass Index.
3. BSA. Body Surface Area.
4. CIS. Clinical Information System.
5. CP. Clinical Pharmacy.
6. CPS. Clinical Pharmacokinetic Services.
7. DD. Dangerous Drugs.
8. DIC. Drug Information Centre.
9. EEFO. Early Expiry First Out.
10. FIFO. First In First Out.
11. IP. In Patient.
12. IV Ad. Intravenous Admixtures.
13. LIS. Laboratory Information System.
14. MADRAC. Malaysian Adverse Drug Reaction Committee.
15. MOH. Ministry of Health.
16. MRN. Medical Record Number.
17. NDD. National Drug Database.
18. OP. Out Patient.
20. PMS. Person Management System.
22. WF. Workflow.
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INVENTORY MANAGEMENT MODULES

1. Name of The Department 119
2. Business Function 119

Contents
3. Range of Services 119
4. Types of Services 119
5. Clients 119
6. Operational Policies 119
7. High Level Workflows 125
8. Mapping of the Work Process / 138

Policy
9. Assumptions 156
10. Glossary 157
11. Abbreviations 160

BUSINESS FUNCTION MODEL – PHARMACY INFORMATION
SYSTEM
1. Name of the Department – Pharmacy Department.
2. Business Function – Inventory Management.
3. Range of services:-
3.1. Procurement.
3.2. Supply.
3.3. Transportation.
3.4. Inventory Management.
4. Type of services:-
4.1. Store Management:-
4.1.1. Procurement:-
4.1.2. Storage.
4.1.3. Supply.
4.2. Supply to hospitals and health centres.
5. Clients:-
5.1. Internal:-
5.1.1. Departments in the hospitals and health centres within the district.
5.2. External:-
5.2.1. Other organisation within Ministry of Health(MOH).

5.2.2. Concession Company.
5.2.3. Other suppliers.
6.1. Services Standards:-
6.1.1. The Chief Pharmacist shall be the system administrator for the Pharmacy
Information System (PhIS).
6.1.2. The highest level of security shall be provided to all stores.
6.1.3. There shall be one database for monitoring the procurement and supply
of pharmaceutical products in the hospital.
6.1.4. All procedures and regulations shall follow the Treasury Instructions and
Government Procedures and MOH guidelines for procurement.
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6.1.5. The Pharmacy Store shall be responsible for procurement and supply of
all pharmaceutical products to the hospitals and health centres.
6.1.6. The Pharmacy Store shall procure APPL items from Concession Company
and shall follow a standard procurement procedure.
6.1.7. For non-APPL items, procurement shall be made through local purchase
order.
6.1.8. The Pharmacy Store shall supply pharmaceutical drug products through
pharmacy sub-store and medical consumables shall be supplied directly
to the wards and units.
6.1.9. Such supply shall be made in accordance to the institution policy.
6.2. Service hours:-
6.2.1. Service hours shall be in accordance to the institution policy.

6.2.2. Only authorised personnel shall be allowed to enter Pharmacy Stores.
6.3. Pharmaceutical Inventory Management:-

6.3.1. Pharmacy Store:-
6.3.1.1. The Pharmacy department shall be responsible for purchasing

requirements for the hospital and other institutions under its
responsibility.
6.3.1.2. The purchasing requirement shall only include drug and medical
items.
6.3.1.3. All purchases in the Pharmacy Store shall be authorised by
Chief Pharmacist.
6.3.1.4. All products shall have standardized code as a unit identifier.
6.3.1.5. Stock keeping and control shall be maintained by the use of
system. Stock level shall be updated all the time.
6.3.1.6. Bar codes shall be made available for electronic identification
and inventory management.
6.3.1.7. All transactions shall be reflected / integrated with General
Ledger in the account system.
6.3.1.8. The Pharmacy Store shall not issue inventory items directly to
patients.
6.3.1.9. Stock verification by stock verifier appointed by the Hospital
Director shall be carried out periodically.
6.3.1.10. Stocktaking shall be done periodically.
6.3.2. Procurement:-
6.3.2.1. Purchase requisition shall be generated from Pharmacy Store,

sub-stores and units.
6.3.2.2. Non-standard items requisition shall be made upon request
from the requesting unit.
6.3.2.3. Drugs to be included in the hospital formulary must be in the
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MOH drug list or approved by the Director General of Health.
6.3.2.4. New medical item shall be approved by Head of Department
and Chief Pharmacist/Hospital Director
6.3.2.5. The Procurement of inventory items shall practice Just In Time
(JIT) Delivery to avoid overstocking and slow moving stocks.
6.3.3. Standard Items:-
6.3.3.1. Procurement of Standard Items shall be according to

schedule.
6.3.3.2. All orders shall be authorised by the pharmacist.
6.3.3.3. Confirmation of ability to supply from Concession Company
shall be within 7 days after receiving the order.
6.3.3.4. Purchase order shall be generated upon receiving the
confirmation online from Concession Company.
6.3.3.5. All transactions with the Concession Company shall be
interfaced with the Pharmacy Information System.
6.3.4. Central Contract:-
6.3.4.1. Selected standard items shall be purchased under Central

Contract.
6.3.4.2. Items purchased above the amounts pre-determined by
Treasury Instruction shall be proposed for tender.
6.3.5. e-Perolehan (Electronic Procurement):-
6.3.5.1. List of companies under e-Perolehan shall be made accessible

to the pharmacy department in the hospital.
6.3.5.2. Items purchased under e-Perolehan shall be made online upon
approval of the chief pharmacist, pharmacist or authorised
personnel.
6.3.5.3. The Pharmacy Information System shall be interfaced with e-
Perolehan .
6.3.6. Non-standard items:-
6.3.6.1. Items shall only be made available upon request and approval
of the chief pharmacist.
6.3.6.2. Drugs that are not in MOH Drug List shall be made available
upon request and approval from Director General of Health.
6.3.7. Payment:-
6.3.7.1. All processes for payment shall be made by Financial Unit of

the respective institution.
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6.4. Inventory Distribution:-
• All requesting units and authorised personnel shall be registered in the
system.
• Authorised staff from requesting unit shall be responsible for indenting and
collection of the supplies.
• All requisitions shall be submitted and supplied on scheduled days.
• Replenishment shall be based on par level or according to the unit
requirement.
• Supplies of DD from Pharmacy Store shall be made only to pharmacy sub-
store.
• In circumstances of acute shortage of stock in pharmacy sub-store,
during/after office hour, supply shall be made possible with approval of the
Pharmacist in-charge. This supply shall be recorded as advanced issue.
• Stock transfer of pharmaceutical items within or inter-hospital pharmacy
sub-store shall be documented for tracking purposes.
• All supplies to the requesting unit shall be charged. Report on total charge
for the unit shall be generated monthly.
• All stores must practice “First in First out (FIFO)” and “Early Expiry First Out
(EEFO)” method of issuing inventory items.
• Fixed location of storage item shall be practiced in all stores.
6.4.1. Community Polyclinics/Clinics:-
6.4.1.1. Supply of pharmaceutical products and medical items shall be

based on the budget allocated to the hospital by the community
polyclinics/clinics.
6.4.2. Transportation of Pharmaceutical Products from Pharmacy Store:-
6.4.2.1. All vaccine shall be transported following “Cold Chain”

procedure.
6.4.2.2. All perishable items shall be transported using cold-box:
6.4.2.3. All hazardous drugs shall be properly labelled and packed in
separate box.
6.4.2.4. The pharmacist at the sub-store shall collect all dangerous
drugs and selected psychotropic drugs.
6.5. Stock Management for Pharmacy Sub-store:-

• The pharmacy sub-store shall be responsible for supplying pharmaceutical
products to the units in the Hospitals.
• Supply of pharmaceutical products through satellite pharmacy shall be
determined by institution policy.
• Minimal stock shall be stored according to the requirement upon the
approval of the pharmacist in charge.
• List of low or nil items shall be provided to the prescribing officer.
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6.5.1. Imprest Stock Supply:-
6.5.1.1. “After office hour stock (AOH)” and imprest stock par level shall
be decided by pharmacist. Items and quantity of imprest stock
shall be reviewed from time to time.
6.5.1.2. The ward/unit personnel shall be responsible to check, update
and maintain stock level. Counter checking shall be done by the
pharmacy personnel periodically.
6.5.1.3. Request order shall be triggered based on imprest stock
availability.
6.5.1.4. Replenishment shall be done on “top-up” basis.
6.5.1.5. AOH shall be used strictly after office hours. Stock level shall be
checked daily and replenished as per scheduled decided in the
hospital policy.
6.5.1.6. Supplies issued from pharmacy shall be checked and signed by
the receiving personnel.
6.5.1.7. Supply of disinfectant will be triggered based on the period of
utilization as determined by the institution policy.
6.5.2. Supply for inpatient:-
6.5.2.1. Supply of inpatient order medication shall follow unit of use/unit

of dose as a policy in accordance to institutional policy.
6.5.2.2. All Medication order shall have complete details of patient and
prescribing officer.
6.5.2.3. Patient’s name, RN and bed number, ward status shall be
updated daily by ward staff.
6.5.2.4. Drugs prescribed shall be checked for availability and the
prescribing officer shall be contacted for alternative drugs if
needed.
6.5.2.5. Medication shall be prepared accurately and correctly according
to Medication order.
6.5.2.6. Every pack should be individually labelled according to patient’s
name, bed number, RN, ward, name of medication, dosage,
date and quantity supplied.
6.5.2.7. Pharmacists shall review patient medication profile from time to
time.
6.5.2.8. Discontinued medication shall be updated daily by ward staff.
Daily list of discontinued medication shall be generated.
6.5.2.9. Drugs that had been prescribed shall be returned to pharmacy
if unused.
6.5.2.10. Inventories shall be updated upon completion of medication
administration.
6.5.3. Supply for Discharged Patient:-
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6.5.3.1. All medication order for discharged patient shall be completed
with patient details and medication order details.
6.5.3.2. Availability of the medication prescribed shall be checked and
the prescribing officer shall be contacted for clarification if
needed.
6.5.3.3. Medications shall be prepared accurately and dispensed
according to the prescribed dose.
6.5.3.4. Bedside dispensing shall be practised.
6.5.3.5. Pharmacist shall provide bedside counselling for selected
patients.
6.5.4. Supply of Dangerous Drugs (DD) to Requesting Unit:-
6.5.4.1. Supply of Dangerous Drugs medications shall follow imprest

stock topping up system.
6.5.4.2. Imprest stock par level shall be decided by pharmacist.
6.5.4.3. Topping up of Dangerous Drugs from pharmacy sub-store to
requesting unit shall be carried out by pharmacy staff depending
on pharmacist availability.
6.5.4.4. Dangerous Drugs can only be received by authorised personnel
as mentioned in the Dangerous Drug Act 1952.
6.5.4.5. All DD used in pharmacy sub-store and the requesting units
must be written in the Record Book in accordance to the
requirements in DD Act.
6.5.4.6. All storage of DD in the requesting unit must be kept in a locked
cabinet and under control by authorised staff only.
6.6. Product Recall:-
6.6.1. Notification of recall products shall be through electronic or written letter.

6.6.2. The pharmacist shall take immediate action to disseminate to all pharmacy
units.
6.6.3. Monitoring of product recall is maintained up to sub-store level only.
However, this may vary based upon hospital policy.
6.6.4. All details of the recall products shall be matched with the information
provided from the NPCB/company concerned. All the related products
shall be withdrawn immediately from all stores and updated from the
respective supply inventories.
6.6.5. Recalled products shall be quarantined and returned back to the
company.
6.6.6. The details of recall product shall be documented and reported to NPCB/
company concerned.
6.7. Procurement Process:-
6.7.1. Procurement shall be made through:-
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6.7.1.1. Concession Company.
6.7.1.2. LPO.
6.7.1.3. Central Contract.
6.7.2. Supply Chain:-
6.7.2.1. Supplier to Pharmacy Store.

6.7.2.2. Pharmacy Store to pharmacy sub-store/units/wards.
6.7.2.3. Pharmacy Store to Community Polyclinics/Clinics.
6.7.2.4. From pharmacy sub store to inpatient/outpatient work station.
6.7.2.5. From inpatient work station to wards and units:-
6.7.2.5.1. Imprest stock.
6.7.2.5.2. Inpatients medication supply.
6.7.2.5.3. Discharge medication.
7. HIGH LEVEL OF WORKFLOWS (depend upon scope of work of hospital):-
7.1. Supply of Pharmaceutical Products and Medical Items from Pharmacy Store to
Pharmacy Sub-Store and Units Workflow - PhIS/IN/WF/1.
7.2. Supply from Inpatient Workstation to wards – Imprest Stock and AOH Workflow
– PhIS/IN/WF/2.
7.3. Back Order from Pharmacy Store to Pharmacy Sub-Store and Units Workflow
–PhIS/IN/WF/3.

7.4. Receiving from Supplier and other MOH Facilities to Pharmacy Store Workflow
-PhIS/IN/WF/4.
7.5. Supply of Dangerous Drug (DD) from Pharmacy Sub-Store to Requesting Unit
Workflow – PhIS/IN/WF/5.
7.6. Replenishment of Stock from Pharmacy Sub-Store to Work Station (supply

counter) Workflow - PhIS/IN/WF/6.
7.7. Inventory Transfer From One Pharmacy Sub-Store To Another Pharmacy Sub-
Store Workflow – PhIS/IN/WF/7.
7.8. Stock Taking at Pharmacy Store and Pharmacy Sub-Store Workflow

– PhIS/IN/WF/8.

7.9. Stock Verification at Pharmacy Store Workflow– PhIS/IN/WF/9.
7.10. Recalled Products Workflow – PhIS/IN/WF/10.
Back To Contents
Supply of Pharmaceutical Products and Medical Items from Medical store to Pharmacy
Sub-Store and Units Workflow
PhIS/IN/WF/1
Pharmacy
Inventory
System
Generate and amend

itemsto be ordered
(PharmacyAsst./ Ward
Staff )
Countercheckand verify
(Pharmacist / Staff -in-
charge)
Submit request order to

Medical Store
(Pharmacist / Staff -in- Sub-Store /Unit
charge) Level
Receive requestorder
(Store keeper / clerk)
No
Procurement
Isit the standard items ?
Workflow
Yes
Checkand approve
request order
(Pharmacist)
No Return to Requesting
Isthe request order Unit
approved ? (Pharmacist / Store
keeper)
Yes
Checkstockavailability
(Store keeper)
No
Backorder
Isthe stockavailable ?
Workflow
Yes
Accept request order

and update inventory
(Store keeper)
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Supply of Pharmaceutical Products and Medical Items from Medical store to Pharmacy
Sub-Store and Units Workflow
PhIS/IN/WF/1
-continued
Print Issue note Issue note

(Store keeper)
Refer to Pharmacist
Is it DD? Yes
(Store keeper)
No
Issue stock Issue stock

(Store keeper) (Pharmacist)
Supply to Unit Supply to Unit

Identify and receive stock Identify and receive stock

(Authorised staff from (Pharmacist from requesting
requesting unit) unit)
Sign issue note and return Sign issue note and return
copy copy
(Authorised staff from (Pharmacist from requesting
requesting unit) unit)
Update and file issue Update and file issue

note note
End
Note:The inventory of Medical Store , pharmacy sub -store and unit must be
updated automatically by the system .
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Supply from Inpatient Workstation to wards - Imprest Stock and AOH Workflow
PhIS/IN/WF/2
Pharmacy
Inventory
System
Generate and amend

Imprest stock and AOH
to be topped up
Asst.)
Imprest Floor Stock Print Imprest Stock and

and AOH List AOH List
(Pharmacy Asst.)
Label :
- Name
Print label - Batch No.
(Pharmacy Asst.) - Expiry Date
Record task and

document findings
(Pharmacy Asst.)
Prepare and label Imprest

Stock and AOH
(Pharmacy Asst.)
Supply and send Imprest

Stock and AOH to Requesting
Unit
(Pharmacy Asst.)
Identify and receive Imprest

Stock and AOH
(Authorised staff from
requesting unit)
Sign Imprest Stock and AOH

list
requesting unit)
End
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Back Order from Medical Store to Pharmacy Sub-Store and Units Workflow
PhIS/IN/WF/3
Start
Retrieve list of back order

(Pharmacist/ Store keeper)
Check the list of back order

Back Order List items and print back order
list.
No
Procurement
Is the item purchased?
Workflow
Yes
Remind supplier to deliver

items
(Pharmacist/Store Keeper)
Enter dates of reminder and

Reminder Letter generate reminder letter for
supplier.
No
Procurement
Is the item delivered ?
Workflow
Yes
Receiving
Workflow
(PhIS/IN/WF 4)
Note : Back order refers to request from sub-store/units to Pharmacy Store
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Receiving from Supplier and other MOH facilities to Medical Store Workflow
PhIS/IN/WF/4
Supplier :
· Pharmaniaga Receive
· Registered Company medical items
· Other MOH facilities
Receive and identify medical

items
(Receiving Store keeper)
· Delivery note (DO)

Check physical received medical
· Purchase order (PO)
items vs. documents/issue note
· Issue note
(Receiving Store keeper)
Inform
No
supplier and Procurement
Correct Item ?
reject DO Workflow
(Pharmacist)
Yes
Record in the bin card and

store item
(Issuing Store keeper)
Update DO in the
system
(IT Store keeper)
No
Is the medical item
End
in a back order list?
Yes
Generate back order

list of requesting unit
(IT Store Keeper)

(IT Store keeper)
Contact unit concern and

supply stock
(Issuing Store keeper)
Identify and receive stock

requesting unit)
Sign issue note and return

copy
requesting unit)
Update issue note

(Issuing Store
keeper)
End
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Supply of Dangerous Drug (DD) from Pharmacy Sub-Store to Requesting Unit Workflow
PhIS/IN/WF/5
Pharmacy Location : Pharmacy Sub-Store

Inventory
System
Generate list for items to

be replenished using
template
( Pharmacist)
Check stock availability

(Pharmacist)
No
Medical Store
Is stock available ? Supply Workflow
PhIS/IN/WF/1
Yes
Issue stock and

update inventory
(Pharmacist)

(Pharmacist)
Issue stock
(Pharmacist)
Record transaction Report

and generate usage
report
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Supply of Dangerous Drug (DD) from Pharmacy Sub-Store to Requesting Unit Workflow
- continued
PhIS/IN/WF/5
A
Location : Requesting Unit
Approach staff in charge

( Pharmacist )
Check against requesting

unit record book and
physical stock
( Pharmacist )
Counter check against

record in the inventory
system
(Pharmacist)
Request written explanation from staff No

in charge of the requesting unit. Explanation Refer to higher authority
Does it tally ? No
(Pharmacist) accepted ? ( Pharmacist )
Yes
Yes
Do correction in the record book

Top up DD stock of the requesting unit
( Pharmacist ) ( Pharmacist )
Update the record book of

the requesting unit
(Pharmacist)

(Authorised Staff from
Requesting Unit)

copy
(Authorised Staff from
Requesting Unit)
Location : Pharmacy
Update and file issue note Sub -Store
(Pharmacist)
End
Back To Contents
Replenishment of Stock from Pharmacy Sub-Store to Workstation (supply counter)
Workflow
PhIS/IN/WF/6
Pharmacy
Inventory
Generate and review

usage report
Asst.)
Update replenish item

template and submit Workstation
Asst.)
Retrieve , check and

approve request Sub-Store
Asst.)
No Return to Workstation
Is the request
approved?
Asst.)
Yes
Check stock availability

Asst.)
No Medical Store
Is stock available ? Supply
Workflow
Yes
Accept request and
update inventory
Asst.)
Print Issue note

(Pharmacist/Pharmacy Issue note
Asst.)
Issue stock
Update inventory,
record task and
document findings
(Pharmacist /Pharmacy
Asst.)

Workstation
Asst.)

copy
(Pharmacy Asst.)
File issue note

(Pharmacy Asst.)
End
Back To Contents
Inventory Transfer From One Pharmacy Sub-Store To Another Pharmacy Sub-Store
Workflow
PhIS/IN/WF/7
Pharmacy
Inventory
System
Receive list of low-in-

stock items from Medical
Store
Asst.)
Check stock availability in

sub-store
Asst.)
Check stock availability in

other sub-store
Asst.)
Contact Staff in charge

(Pharmacist / Pharmacy Asst.)
Agree to transfer No Procurement

stock? Workflow
Yes
Stock Transfer Record stock transfer

Note and stock transaction
(Supply Unit Pharmacist /
Pharmacy Asst. )
Receive transfer stock

(Receiving unit Pharmacist /
Pharmacy Asst.)
Update transfer stock

received
(Receiving Unit
Pharmacist / Pharmacy
Asst. )
End
Back To Contents
Stock Taking at Medical Store and Pharmacy Sub-Store Workflow
PhIS/IN/WF/8
Start
Plan of stock taking

(Pharmacist)
Freeze all transaction

(Pharmacist)
Generate and print

count sheet report for
Count sheet report
stock taking
(Pharmacist/Store
Keeper)
Check and count physical

stock
(Store Keeper)
Enter stock count

(Pharmacist/
storekeeper)
Variance Generate variance

Report report
(Pharmacist)
No
Approve variance
report
(Chief Pharmacist)
Check and investigate

Approve? variance report Accept ?
(Pharmacist)
Yes
Yes
Stock adjustment
(Pharmacist)
Pharmacy
Inventory
System
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Stock Verification at Medical Store Workflow
PhIS/IN/WF/9
Arrival of stock verifier /

Start
specified date for stock
verifying
Plan of stock verifying

(Pharmacist)
Freeze transaction
during the verifying
period
(Pharmacist)
Generate and print

count sheet for stock
Count sheet
verifying
(Pharmacist/Store
Keeper)
Check and count physical

stock
(Stock Verifier and Store
Keeper)
Receive instruction from

Prepare variance
Medical and Health State
report (KEW.300-K)
Tally ? No Director to give justification
(Stock Verifier)
and rectify variance
(Pharmacist)
Yes
Sign and put date on the Check and investigate

bin card (KEW.300-J4) variance report as instructed
(Stock Verifier) by the Medical and Health
State Director
(Pharmacist)
Receive inspection report

KEW.300-S from Stock Stock adjustment
Verifier (Pharmacist)
(Pharmacist)
Sign Certificate of Prepare justification report

Verification (KEW. 300-T) and send to the Medical and
and prepare report Health State Director
(KEW.300—U1) (Pharmacist)
(Pharmacist)
End File documents

(Pharmacist)
End
Back To Contents
Recalled Products Workflow
PhIS/IN/WF/10
Start
Receive notification of Recall

Products and Complaints Via email/ documents
from user delivery
(Chief Pharmacist)
Inform DIS Pharmacist Via email/ documents

(Chief Pharmacist) delivery
Disseminate to Head of
Pharmacy Unit Via email/ documents
(DIS Pharmacist) delivery
Receive documents
(Head of Unit Pharmacist)
Is the product purchased by No File the documents

The Medical Store ? (Pharmacy Asst./ Store End
( Store Pharmacist) keeper)
Yes
No
Is the product
available?
Yes
Check and match
product
(Pharmacy Asst./ Store
keeper)
Withdraw and quarantine

product All recall products shall be
(Pharmacy Asst./ Store sent to the Medical Store
keeper)
Yes Update bin card and file

Send report and return items to
Need to send Generate and print report records/documents
Supplier
to supplier ? (Pharmacy Asst./ Store keeper) (Pharmacist Asst./Store
(Pharmacy Asst./ Store keeper)
keeper)
No No
Record task and

document findings
(Pharmacy Asst./ Store
keeper)
Generate and print report

(Pharmacy Asst./ Store Report
keeper)
Send report to NPCB /

company
(Store Pharmacist)
End
Note:-
All quarantined products shall not be allowed to be used in the hospital.
Product recall shall be at done at the healthcare facility level.
Back To Contents
8 MAPPING OF WORK PROCESS/SYSTEM
FUNCTIONALITIES AND OPERATIONAL POLICIES
Supply of Pharmaceutical Products and Medical Items from Pharmacy Store to Pharmacy Sub-
Store and Units – PhIS/IN/WF/1.
1. Generate and • Ability to add new items in the • Only authorised

amend items to be template. personnel shall be
ordered. allowed to generate
• Ability to provide and update and amend items to be
template on par level of all items. ordered.
• Ability to select items that need to be

ordered.
2. Submit request to • Ability to alert Pharmacist/Staff-in- • Only authorised

Pharmacy Store. charge of incoming request. personnel shall be
allowed to submit
request.
3. Receive request • Ability to integrate with OMS. • Only authorised

order. personnel are allowed
• Ability to alert the incoming request. to access PhIS.
• Ability to specify items i.e. APPL, • All requesting unit and

Central Contract, Direct Issue, etc. authorised personnel
must be registered in
• Ability to identify type of drug (DD the system.
and non-DD products).
• Authorised staff
from requesting unit
is responsible for
identification and
collection of the
supplies.
• All requisition shall be

submitted and supplied
on scheduled days.
• Replenishment shall
be based on par level
or according to the unit
requirement.
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• Supplies of DD are
allocated to pharmacy
sub-store only.
• In circumstance of
acute shortage of
stock in pharmacy
sub-store after office
hour, supply will be
made possible with
approval of pharmacist
in charge. This supply
will be recorded as
advanced issue and
deducted from stock
inventory.
• Borrowing of
pharmaceutical items
within or inter-hospital
pharmacy store shall
be documented for
tracking purposes.
• All supplies to the

requesting unit shall
be charged. Report
on total charge for the
unit shall be generated
monthly.
• All DD products
shall be handled by
Pharmacist.
4. Check and • Ability to view and approve request

approve request order.
order.
5. Check stock • Ability to check stock inventory.

availability.
6. Return to • Ability to return the disapproved
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requesting unit. order back to the requesting unit.
• Ability to alert the requesting unit that

the order has not been processed
and probably need to be counter
checked and verified once again.
7. Accept request • Ability to accept request from OMS. • All stores must
order and update practice “First in
inventory. • Ability to update inventory. First out (FIFO) “and
“Early Expiry First
Out (EEFO)” method
of issuing inventory
items.
• Fixed location of
storage items shall be
practiced in all stores.
8. Print Issue note. • Ability to generate and print issue

note. The issue note shall contain
the following items:-
o Date of request.
o Name of requesting unit.
o Name of item/ drug.
o Strength of drug.
o Formulation.
o Quantity request.
o Quantity supply.
o Storage condition.
o Date of supply.
o Name of issued person.
o Name of receiver.
9. Update and file • Ability to update issue note. • The inventory of

issue note. Pharmacy Store,
• Ability to generate Work Load report pharmacy sub-store
i.e:- and unit must be
o No of request received. updated automatically
o No. and list of items supplied. by the system.
o No. and list of items transferred to
back order.
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• Ability to generate and print slow

moving items report.
• Ability to generate and print near

expired items report.
10. General function. • Ability to view and print costing

report of each individual department/
unit for selected period.
• Ability to view and print costing

report of total drug or medical
disposable or medical equipment
usage for selected period.

moving and near expiry date stocks
based on specified duration of time
and mass email to sub-stores and
other hospitals.
• Ability to generate report of expired

stocks item.
• Ability to auto generate list of items

to be condemned in the specified
template.
• Ability to generate report on total

stock out (zero stock) at a scheduled
period.
• Ability to generate detailed report

on items unable to be supplied or
partial supply based on sub-store
workstation or requesting unit.
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Supply from Inpatient Workstation to wards – Imprest Stock and AOH – PhIS/IN/WF/2.
1. Generate and • Ability to display and generate • Only authorised

amend imprest imprest stock and AOH list for personnel are allowed
stock and AOH to imprest stock top-up. to access PhIS.
be topped up.
• Ability to alert PhIS once AOH items • Pharmacist and staff-
have been used. in-charge in ward
shall be responsible to
• Ability to alert PhIS once imprest determine the par level
stock is below par level. of imprest stock and
“after office hour stock
• Ability to confirm the replenishment (AOH)”.
amount.
• Items and quantity of
imprest stock shall
be maintained and
reviewed from time to
time.
• The pharmacy staff is

responsible to check,
update and maintain
stock level.
• AOH shall be used

strictly after office
hours.
• Ward staff shall

update the usage of
imprest stock and AOH
immediately.
• Details of prescription
have to be recorded to
control usage.
• Checking and supply

of imprest stock shall
be scheduled based
on local policy.
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• Replenishing the
imprest stock shall be
done on “top-up” basis.
2. Print imprest stock • Ability to generate and print Imprest

and AOH list. Stock and AOH list.
3. Print label. • Ability to generate and print label. • Quantity supplied

The label shall contain the following:- will be according to
o Patient name. amount used up from
o Drug name. stock level.
o Drug strength, dosage, frequency.
o Batch number.
o Manufacturing date.
o Expiry date.
4. Identify and • Supplies received from

receive imprest pharmacy have to be
stock and AOH. checked and signed by
the receiving staff for
correct specification,
integrity and quantity.
5. Record task • Ability to update inventory.

and document
findings. • Ability to generate report of usage
and cost by unit and discipline.
• Ability to view and generate report

of number, list and cost of imprest
stock and AOH to individual ward for
specified time.


stocks item.

template.
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Back Order from Pharmacy Store to Pharmacy Sub-Store and Units – PhIS/IN/WF/3.
1. Retrieve list of • Ability to retrieve list of back order. • Only authorised

back order. personnel are allowed
• Ability to cancel back order items. to access PhIS.
2. Check the list of • Ability to view list of items ordered.

back order items
and print back • Ability to print back order list.
order list.
3. Enter date of • Ability to allow free text to enter date

reminder and of reminder and reason of delay in
generate reminder the procurement system.
letter for supplier.
• Ability to generate reminder letter.
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Receiving from Supplier and other MOH facilities to Pharmacy Store - PhIS/IN/WF/4.
1. Inform supplier • Ability to access procurement

and reject DO. system.
• Ability to document remarks for

rejecting product in procurement
system.
2. Record in the bin • As stated in ‘Tatacara

card and store Pengurusan Stor’
item. (TPS).
3. Update DO in the • Ability to update inventory record.

system.
4. Generate back • Ability to generate back order list of

order list of previous requesting orders.
requesting unit.
5. Print Issue note. • Ability to print issue note.
6. Update issue • Ability to update issue note.

note.
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Supply of Dangerous Drug (DD) from Pharmacy Sub-Store to Requesting Unit– PhIS/IN/WF/5.
1. Generate • Ability to alert incoming request. • Authorised personnel

replenish item shall be allowed to
using template. • Ability to retrieve list of request. access PhIS.
• Ability to capture the usage of • All requisition shall be

dangerous drugs for replenishing submitted and supplied
purposes. on scheduled days.
• Topping up of
dangerous drugs
from pharmacy sub-
store to requesting
unit shall be carried
out by pharmacist.
If topping up cannot
be carried out, all
empty ampoules used
shall be retained for
exchange.
• All DD used in the

ward must be written
in the record book with
patient detail according
to the requirement in
DD Act.
• Replenishment shall
be based on minimum-
maximum stock level.
• The pharmacist
in-charge shall be
responsible to update
and maintain min/ max
stock level.
• Report on total usage

for the requesting unit
shall be generated
monthly.
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2. Check stock • Ability to check availability of stock in

availability. pharmacy sub-store.
3. Issue stock and • Ability to issue out stock through the

update inventory. system and update inventory.
4. Print issue note. • Ability to generate and print issue

note.
5. Record • Ability to record transaction.

transaction
and generate • Ability to generate report on usage of
usage report. DD by date.
6. Counter check • Ability to check the transaction

against record status of the requesting unit in the
in the inventory system.
system.
7. Update the record • All supplies to the

book of the requesting unit shall be
requesting unit. recorded and updated
accordingly in the
record book.
8. Sign issue note • Only authorised staff

and return copy. shall sign issue note.
9. General function. • Ability to view and generate report of

number, list and cost of DD supplied
to individual department/ unit for
specified time.


stocks item.

template.
Back To Contents
Replenishment of Stock from Pharmacy Sub-Store to Workstation (supply counter) -

PhIS/IN/WF/6.
1. Generate and • Ability to generate usage report from • Authorised personnel

review usage OMS. shall be allowed to
report. access PhIS.
2. Update replenish • Ability to update replenish items.

item template and
submit. • Ability to convert quantity usage to
the minimal stock keeping quantity.
3. Retrieve, check • Ability to alert incoming request. • All requisition shall be

and approve submitted and supplied
request. • Ability to retrieve list of request. on scheduled days.
• Ability to view and approve request. • Replenishment shall

be based on min-max
stock level.
• The work station

personnel shall
be responsible to
update and maintain
minimum/ maximum
stock level.
• All supplies to the

work station shall be
charged. Report on
total usage for the
work station shall be
generated monthly.
4. Return to • Ability to return the unapproved

Workstation. request back to the workstation.
5. Check stock • Ability to check stock inventory.

availability.
6. Accept request • Ability to accept request from work

and update station.
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inventory. • Ability to update inventory.
7. Print issue note. • Ability to update issue note.
• Ability to generate and print total

usage and cost of items issued to
work station by date or month report.
8. Update inventory, • Ability to update inventory records.

record task
and document • Ability to generate report of stock
findings. received.
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Inventory Transfer from one Pharmacy Sub-Store to another Pharmacy Sub-Store –

PhIS/IN/WF/7.
1. Receive list of • Ability to display and print list of low- • Only authorised
low-in-stock items in-stock items. personnel shall be
from Pharmacy allowed to access
Store. • Ability to alert incoming list of low-in- PhIS.
stock items.
2. Check stock • Ability to view stock level of other • Only authorised

availability in sub- sub-store. personnel shall be
store. allowed to view.
• Ability to alert Pharmacy Store once
the items not available in all sub-
stores.
3. Check stock • Ability to view stock level of other • Only authorised

availability from sub-store. personnel shall be
other sub-store. allowed to view stock
availability.
4. Transfer stock. • Only authorised

personnel shall be
allowed to transfer
stock.
5. Record stock • Ability to record stock transfer and

transfer and stock generate stock transfer note.
transaction.
• Ability to generate report of stock
transfer.
6. Update transfer • Ability to acknowledge receiving of

stock received. stock.
• Ability to update transferred stock.
7. General function. • Ability to view and generate report

of number, list and total cost of stock
transferred.
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Stock Taking at Pharmacy Store and Pharmacy Sub-Store – PhIS/IN/WF/8.
1. Freeze all • Ability to freeze any transaction. • Stocktaking shall be

transaction. done in accordance to
‘Tatacara Pengurusan
Stor’ (TPS), at least
once a year.
2. Generate and • Ability to view, generate and print

print count sheet count sheet report for stock taking.
report for stock
taking. • The count sheet report should
contain the following information:-
o Detail item description:-
• Code.
• Description.
• Batch Number.
• Packing.
• Quantity.
• Type of item.
• Location.
o Detail transaction of receiving
stock, issuance of stock and cost
involved.
o Stock expiry date.
o System balance stock and a
column for physical stock to be
filled during stock taking.
3. Enter stock count. • Ability to update stock count and

match with the inventory stock.
4. Generate variance • Ability to generate variance report of

report. excess or deficit stock.
5. Approve variance • Ability to alert Chief Pharmacist on • Only authorised

report. stock inventory adjustment. personnel shall be
allowed to approve
• Ability to allow approval of stock stock adjustment.
inventory adjustment of the variance
report.
6. Stock adjustment. • Ability to adjust stock. • Only authorised
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personnel shall be
allowed to do stock
adjustment.

of number, list and cost of adjusted
stock items for specified time.
• Ability to generate report of annual

turn over rate for all standard items.
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Stock Verification at Pharmacy Store – PhIS/IN/WF/9.
1. Freeze transaction • Ability to freeze all transactions. • Stocktaking shall be

during the done twice a year
verifying i.e before the end of
period. June and December
respectively, in
accordance to
‘Tatacara Pengurusan
Stor’ (TPS).
2. Generate and • Ability to view, generate and print

print count sheet inventory report for stock verifying.
for stock verifying.
• The report should contain the
following information:-
o Detail item description:-
• Code.
• Description.
• Batch Number.
• Packing.
• Quantity.
• Type of item.
• Location.
o Detail transaction of receiving
stock, issuance of stock and cost
involved.
o Stock expiry date.
o System balance stock and a
column for physical stock to be
filled during stock taking/ stock
verification.
3. Stock adjustment. • Ability to adjust stock. • Only Chief Pharmacist

/ Pharmacist shall be
allowed to do stock
adjustment.
4. General function. • Ability to view and generate report • Stock Verifier shall be
of number, list and cost of adjusted appointed by Hospital
stock items for specified time. /Institutional Director.
• Ability to generate report of annual

turn over rate for all standard items.
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Recall Products – PhIS/IN/WF/10.
1. Receive • Ability to alert on incoming • Only authorised

notification of information regarding recall product. personnel shall be
recall products allowed to access
and inform DIS PhIS.
Pharmacist.
• NPCB shall be
responsible for
informing all hospitals
regarding information
on recalled products
through electronic
communications
followed by written
letter and action taken
accordingly.
• For those received

directly from the
company, the hospital
shall take immediate
action.
• All product complaints

from users have to be
filled in the Product
Complaint Form
(Borang Laporan
Aduan).
2. Disseminate to • Ability to auto generate list of recall

head of pharmacy product on specified template.
unit.
3. Receive • Ability to alert on incoming

documents. information regarding recall product.
4. Check and match • Ability to check and match the • All details of the
products. product recall. recall products will
be matched with the
• Ability to capture products bar code. information provided
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from the NPCB or the

company concerned.
These include type of
medication and batch
number.
5. Withdraw and • All the related products

quarantine shall be withdrawn
products. immediately from all
stores and deducted
from the Pharmacy
Store or consuming
units’ inventory.
• Withdrawn products
shall be quarantined
until replacement stock
is available.
6. Record task • Ability to update stock inventory. • All recall products from
and document the respective stores
findings. shall be deducted from
the respective stores
inventory.
7. Generate and • Ability to generate and print report.

print report.
8. Send report to • Ability to send the report • The type and number
NPCB / company. electronically i.e. via email. of recalled products
shall be documented
and reported to NPCB
and the company
concerned.

of number, list and cost of recall
products.
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9 ASSUMPTIONS
9.1. Only authorized personnel shall be allowed to access to PhIS.

9.2. Interface with concession and e-perolehan will be made available.
9.3. Inventory system will be mandated to use bar coding functionality.
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GLOSSARY 10
No. Terms Definition
1. After Office Hour stock. Items that are kept in the ward but only allowed
to be used strictly after office hour. These items
are drugs that are used frequently, life saving
drug and category A drugs.
2. Approved Product Purchase List. A list of items to be purchased from Concession

Company under concession agreement.
3. Back order. Items that has been ordered / purchased and

has not been supplied/received.
4. Bar code. Product identification.
5. Consuming Units. All locations that store and use the

pharmaceutical products.
6. DD stock. List of dangerous drugs (DD) or selected

psychotropic that is kept under lock and key.
7. Direct Issued. Products supplied direct to requesting unit.
8. Emergency stock. Emergency drugs that are kept in emergency

trolley.
9. Formulary items. Items in MOH Drug List and available in the

hospital.
10. Imprest stock. Common drugs that are kept in the ward at all
time.
11. Issuing Store Keeper. Store keeper in charge of issuing stock from
Pharmacy Store.
12. IT Store Keeper. Store keeper in charge of inventory computer

system.
13. Just In Time Delivery. Stocks to be purchased according to minimal

stock level and to be delivered on time by the
supplier as scheduled.
14. KEW 300-K. Stock Variance Report (‘Penyata Perselisihan

Stok’).
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15. KEW 300-T. Stock Verification Certificate (‘Sijil Verifikasi

Stok’).
16. KEW 300-U1. Stock Verification Report (‘Laporan Verifikasi

Stok’).
17. Medical item. Pharmaceutical, medical and surgical items

including disposables and small equipment.
18. Non-formulary items. Items that are not in MOH Drug List and shall
be only made available upon request and
Director General of Health approval.
19. Non-standard items. Items that are not regularly used and not stored
in Pharmacy Store.
20. Out of stock items. Items that are in MOH Drug List but not
available during the period when needed.
21. Par Level. Minimum and maximum level.
22. Pharmaceutical products. Drugs.
23. Product Recall. Product recall is a process taken by the NPCB,

manufacturer, importer or wholesaler to remove
or withdraw a particular drug or product from all
links of distributions.
24. Receiving Store Keeper. Store keeper in charge of receiving stock from
the supplier.
25. Registered Company. The list of company approved by Ministry of

Finance for procurement with all government
agencies.
26. Return drug. Unused drug that is returned because of

discontinuation prior to discharge. These drugs
are usually costly e.g. list A or uncommon drug.
27. Standard items. Items that are made available in the Pharmacy
Store including APPL and non-APPL.
28. Stock level. Amount of drugs maintained as imprest stock.
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The amount is determined by the ward sister

and pharmacist.
29. Sub-store. Store located in individual unit, i.e. outpatient,

inpatient, satellite, PN, CDR, TDM, IV
admixture, sterile, non-sterile and etc.
30. Unit of use. Supply of medications to inpatients through

medication order on an individual basis for a
fixed period of time.
31. Unit dose. Supply of medications to inpatients through

medication order on an individual and daily
basis.
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11 ABBREVIATIONS
1. AOH. After Office Hour Stock.
2. APPL. Approved Product Purchase List.
3. CDR. Cytotoxic Drug Reconstitution.
4. DD. Dangerous Drug or selected psychotropic drug.
5. DIS. Drug Information Service.
6. DO. Delivery Order.
7. EEFO. Early Expiry First Out.
8. FIFO. First in first out.
9. IN. Inventory.
10. LPO. Local Purchase Order.
11. MOH. Ministry of Health.
12. NPCB. National Pharmaceutical Control Bureau

(Biro Pengawalan Farmaseutikal Kebangsaan).
13. OMS. Order Management System.
15. PN. Parenteral Nutrition.
16. PO. Purchase Order.
17. RN. Registration Number.
19. WF. Workflow.
Back To Contents
APPENDIX – MEMBERS OF EXPERT GROUP

MEMBERS OF EXPERT GROUP:-
• Pn. Hasnah bt. Ismail - Bahagian Perkhidmatan Farmasi KKM.

• Tn. Haji Farid Wong Abdullah - Bahagian Perkhidmatan Farmasi KKM.
• Puan Rosidah bt. Md. Din - Bahagian Perkhidmatan Farmasi KKM.
• Dr. Ghazali Hasni Hj. Md. Hassan - Unit Core Team (THIS).
• Dr. Za’ba bin Baba - Unit Core Team (THIS).
Medication Order Management Module Group:-
1. Puan Kamarunnesa bt. Mokhtar Ahmad Hospital Serdang.

2. Puan Siti Norlina bt. Mohd Said Hospital Putrajaya.
3. Puan Norlida bt. Ibrahim Hospital Kuala Lumpur.
4. Puan Rosiah bt. Harun Hospital Serdang.
5. Puan Nik Norlehanis bt. Nik Mustafa Hospital Serdang.
6. Encik Zainal Abidin bin Zainuddin Hospital Seremban.
7. Puan Lan Fha @ Goh Lan Fah Hospital Serdang.
8. Puan Safiah Idris Hospital Ampang.
Clinical Pharmacy & Manufacturing Module Group:-
1. Puan Fuziah bt. Abdul Rashid Hospital Kuala Lumpur.

2. Cik Sameerah Shaik Abdul Rahman Bahagian Perkhidmatan Farmasi.
3. En. Wong Kok Thong Hospital Selayang.
4. Pn Fadilah bt. Othman Hospital Selayang.
5. Cik Mariam Bintarty bt. Rushidi Hospital Kuala Lumpur.
6. Pn Rosminah bt. Mohd Din Bahagian Perkhidmatan Farmasi.
7. Dr. Nour Hanah bt. Othman Bahagian Perkhidmatan Farmasi.
8. Puan Hamidah Arsal Hospital Ampang.
9. Cik Siti Zaleha bt. Mat Jusoh Hospital Serdang.
10. Puan Salasiah bt. Abdullah Hospital Ampang.
11. Puan Asiah bt. Mohamad Hospital Serdang.
Inventory Management Module Group:-
1. Puan Basariah bt. Naina Hospital Seremban.

2. Puan Fatimah bt. Abdul Rahim Hospital Selayang.
3. Puan Norma bt. Abdullah Hospital Ampang.
4. En. Ahmad Zaki bt. Ramli Bahagian Perkhidmatan Farmasi.
5. Cik Sarah Nagalingam Hospital Ampang.
6. Puan Helen Jety a/k Paim Hospital Ampang.
7. Puan Lim Siew Laun Hospital Kuala Lumpur.
8. En. Dzahari Ahmad Hospital Kajang.
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SECRETARIAT:-
• Datin Dr. S. Selvaraju - Unit Telekesihatan MSC-KKM.

• Dr. Fazilah bt. Shaik Allaudin - Unit Telekesihatan MSC-KKM.
• Dr. Syed Amin Hussaini Al Edrus - Solution Protocol Sdn. Bhd.
• En. C.P. Chan - Medical Online Sdn. Bhd.
• En Jazlan bin Abdul Rahman - Solution Protocol Sdn. Bhd.
• Cik Zunaidah bt. Mohamad Zin - Hospital Kuala Lumpur.
• Sr. Sarniah Sidek - Information Documentation System.
• Sr. Lim Guat Huay - Information Documentation System.
TRANSCRIBERS / TYPIST:-
• Puan Saliza bt. Husin - Medical Online Sdn. Bhd.

• Cik Marzadalinda bt. Zakaria - Medical Online Sdn. Bhd.
• Cik Nur Azian - Solution Protocol Sdn. Bhd.
• Cik Sanisah Lairy - IDS, MOH Putrajaya.
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List Of Participants Of National Consensus Meeting On Health Informatics Standards HUKM
08th May 2006.
Members :-
1. Dr. Rosnah Hadis - Director, Planning and Development

Division, MOH.
2. Mr.Lai Lim Swee - Deputy of Director, Pharmacy Division,
MOH.
3. Dr. Mohd Arif Mohd Hashim - Chief Pathologist, Hospital Kuala
Lumpur.
4. Dr. Zaharah Musa - Chief Radiologist, Hospital Selayang.
Speakers :-
1. Tan Sri Dato’ Dr. Abu Bakar Suleiman - Chairman, TC Health Informatics,
SIRIM.
2. Datin Dr. S. Selvaraju - Information and Documentation
System Unit, MOH.
3. Dr Fazilah Shaik Allaudin - Planning and Development Division,
MOH.
4. Dr. Zanariah Alias - Pathologist, Hospital Ampang.
5. Dr. Faraizah Abdul Karim - Deputy Director, National Blood Bank.
6. Pn. Kamarunnesa Mokhtar Ahmad - Pharmacist, Hospital Serdang.
7. Mr. Daud Ismail - Radiographer, Hospital Selayang.
Participants:-
1. Pn. Maria Christina Stephensons SIRIM.

2. Dato’ Dr. Jai Mohan MHIA.
3. Dr. Chong Su-Lin SUNWAY MEDICAL CENTRE.
4. Ms. Soh Thai Lin SUNWAY MEDICAL CENTRE.
5. Mr.Lee Kok Khin SUNWAY MEDICAL CENTRE.
6. Ms. Ng Leng Yau SUNWAY MEDICAL CENTRE.
7. Rachel Lim SUNWAY MEDICAL CENTRE.
8. Eric Yin SUNWAY MEDICAL CENTRE.
9. Ching Lai Ling SUNWAY MEDICAL CENTRE.
10. Dr. Hj. Lailanor Hj. Ibrahim Kementerian Kesihatan Malaysia.
11. Sarniah Sidek Kementerian Kesihatan Malaysia.
12. Mohd Mahadzir Tumin Kementerian Kesihatan Malaysia.
13. En. Mohd Rodzi Ismail Lab Link.
14. En. Mohd Shazwan Lui Lab Link.
15. Dr. Wong Kien Seng KOMPAKAR.
16. Jacinta Gan Norli KOMPAKAR.
17. Norli Mohd Nasir KOMPAKAR.
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18. Mohd Hanafiah KOMPAKAR.
19. Ng Boon Swee Nova Msc Bhd.
20. Dylan Suppiah FSBM M’sian.
21. Dr. Badrul Hisham Bahadzor HUKM.
22. Dr.Ahmad Taufik Jamil HUKM.
23. Aieshah Mohd Zubit HUKM.
24. Tengku Norliza Tuan Mohd Ghazali HUKM.
25. Norazlina Ahyat HUKM.
26. Abdul Rahman Bullah HUKM.
27. Pn. Faridah Yusof HUKM.
28. En. Dexter Francis Vandof HUKM.
29. Prof. Madya Dr. Mokhtar Abu Bakar HUKM
30. Sivagengei Kulaveerasingan HUKM.
31. En. Mohd Baharudin HUKM.
32. Pn. Halijah Mohd Yunus HUKM
33. En. Rosmadi Baharin HUKM.
34. Pn. Norrela Mokhtar HUKM.
35. Prof. Madya Dr. Zahiah Mohamed HUKM.
36. Dr. Noordin Younus HUKM
37. Dr. Azmi Mohd Tahir HUKM.
38. Dr. Raja Zahratul Azma HUKM.
39. Abdul Hadi Bin Abdul Rahman HUKM.
40. Dr. Saperi HUKM.
41. Dr. Amirul Muhd Nur HUKM.
42. Halimah Razali HUKM
43. Faridah Abdullah HUKM.
44. Rahimah Rahmat HUKM.
45. Zainal Abdul Ghani HUKM.
46. Dr. Leong Chai Fun HUKM.
47. Kol. Dr. Zulkafli Abd. Rahman MINDEF.
48. Dr. Mohd Ghazali Mohd Taha MINDEF.
49. Selvakumar Gribbles.
50. Lim Chong Eng IJN.
51. Thong Mee Ling IJN.
52. Mizana A. Samad IJN.
53. Gunavathy Kalee KPJ.
54. Ir. Mahdi Muda KPJ.
55. Dr. Anitha K.V KPJ.
56. Yusri Ali KPJ.
57. Ng Boon Swee KPJ.
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Ministry of Health, Malaysia

Copyright @ Ministry of Health Malaysia

Malaysia being progressive in the adoption of Information communication “Technology in Health

The documents that have been developed includes the

• Person Management System

TAN SRI DATUK DR. HAJI MOHD. ISMAIL MERICAN

mission OF THE MINISTRY OF HEALTH

• Attain fully their potential in health.

BUSINESS FUNCTION MODEL

MEDICATION ORDER MANAGEMENT MODULES

7. High Level Workflow 12

8. Mapping of the Work Process / 23

1. Name of the department: Pharmacy Department.

2. Business Function: Medication Order Management.

3.1. Outpatient Order.

4.1. Outpatient Medication Order:-

4.2. Inpatient Medication Order:-

4.2.1. Unit Dose/Unit of Use.

5.1. Internal Clients:-

5.1.1. Within Hospital.

5.2. External Clients:-

5.2.1. Other than MOH Healthcare Facilities.

6.1. Medication Order:-

6.1.1. All medication orders must be prescribed by authorised personnel only

PHARMACY INFORMATION SYSTEM (Version 1.1) 7

6.1.3.1. Patient biodata (name, age, sex, weight, height, MRN).

6.1.7. The pharmacist shall be given access to relevant clinical information as

8 PHARMACY INFORMATION SYSTEM (Version 1.1)

6.2.3. Bedside dispensing shall be practised for inpatient discharges.

6.2.10. A proxy may be allowed to collect medication on behalf of the patient

6.2.11.1. place order.

6.2.13. Drugs dispensed must be appropriately labelled with the following

6.2.13.1. Name of patient.

PHARMACY INFORMATION SYSTEM (Version 1.1) 9

6.3. Management Report:-

6.3.1. Statistic report:-

6.3.1.1. Prescribing pattern/trend.

6.3.2. Management report:-

6.3.2.1. Quality Assurance Programme.

6.3.3. Operational report:-

6.3.3.1. Partial supply.

10 PHARMACY INFORMATION SYSTEM (Version 1.1)

6.6.1. Drug category as defined in MOH Drug List.

6.8.1. Referring healthcare facility.

6.9. The system shall be able to capture collector’s identification (name/contact

PHARMACY INFORMATION SYSTEM (Version 1.1) 11

6.13.1. Name of patient.

7. High Level Workflow (depend upon scope of work of hospital):-

7.1. Outpatient Medication Dispensing Flow (Patient Flow)

7.2. Outpatient Pharmacy Queue Management (Electronic Medication Orders)

12 PHARMACY INFORMATION SYSTEM (Version 1.1)

7.4. Outpatient Pharmacy Receiving And Screening of Medication Orders Workflow

7.5. Outpatient Pharmacy Preparation of Medication Orders Workflow

7.6. Outpatient Pharmacy Dispensing Of Medication Workflow

7.9. Inpatient Pharmacy Dispensing Of Medication for Discharged Patient – Including

PHARMACY INFORMATION SYSTEM (Version 1.1) 13

Verify medication order