Compounding records and traceability · PUB-011 (PUB-011)

From instructions to actual records

Master record F-002 specifies what should happen. Batch record F-003 records what happened: lots, weights, times, equipment, tests, yield, label and signatures. Enter records when work occurs. A correction retains the original information and adds reason, date and identity. Do not pre-sign results or release decisions.

What each source supports

An official monograph can establish formula and tests without publishing a complete stability study. A product label can support active-drug warnings without covering the compounded vehicle. Assess authority, exact edition and claim applicability. References identify their actual scope of support rather than serving as a decorative list.

Dating with explicit conditions

BUD follows evidence for the actual formula or an applicable default after checking its conditions. A default duration is not a stability experiment. Temperature, container, microbiological condition and component expiries constrain the decision. Numerical rules appear in SOP-014 and PUB-013; record batch rationale in F-006.

Safe handover and learning

Handover links the correct patient, preparation, strength, route and dosing device. Assess understanding through demonstration and teach-back. Investigate complaints or failures using evidence rather than automatically assigning one mechanism. CAPA includes an owner, deadline and effectiveness check so the finding produces a concrete improvement.

Data and traceability

Using technical experience does not require publishing identifiable patient information. Public documents describe questions and technical findings without personal details. Full order/material/batch/recipient linkage remains in the pharmacy’s protected system. Research use of data requires appropriate separate governance.

Linkage chain

Order → master-record version → actual lots and weights → tests → label → recipient. Verify unique IDs and quantity reconciliation during recall. If affected containers cannot all be identified, the deviation cannot be considered closed.

Starting point and type of dating constraint

The record separates initiation, completion and handover. BUD runs from initiation. Commercial expiry, in-use limit and a compounded component’s BUD are different constraints and are recorded separately. A specific modifier/vehicle exception needs final-quality justification.

Sources and references

NAPRA — Guidance Document for Pharmacy Compounding of Non-sterile PreparationsMarch 2018, clarification January 2022Sections 5, 6 and 7; master/batch records, delivery, qualityQuality-system implementation; historical BUD table not substituted for 2022 USP revision2026-10-14
PIC/S — Guide to Good Practices for the Preparation of Medicinal Products in Healthcare EstablishmentsPE 010-4, 1 March 2014Chapters 1–9; Annex 2 (nonsterile liquids, creams, ointments)Professional quality-system framework; not automatic national legal adoption or certification2026-10-14
Illinois IDFPR — Nonsterile Compounding Self-Inspection ReportPublic regulatory checklist, accessed 2026-09-12pp. 15–16; USP <795> sections 10.1–10.5Temperature conditions and requirements for supported extension; jurisdiction-specific guidance2026-10-14
European Parliament and Council — Directive 2001/83/ECConsolidated text displayed as current on 2026-09-12Articles 2, 3(1)–(2), 6; consolidated 1 January 2025Specific EU scope exclusions; national pharmacy conditions still require verification2026-09-12
USP — General Chapter <795> FAQsUpdated 1 November 2023; retrieved 14 October 2026Questions 52–66, especially 52, 54–56, 58–59, 61–64Publisher interpretation: optional formula-specific aw testing, initiation-date BUD, stock-component exceptions, exact-formula stability studies and antimicrobial-effectiveness testing. Not Greek law.2026-10-14