Documentation in Pharmacy Practice
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Documentation
• Documentation is a fundamental responsibilities of
• Pharmacy professional’s and is a standard of practice
• Pharmaceutical care is the direct and responsible provision of
medication-related care for the purpose of improving a patient’s
quality of life/care
• Integrating pharmaceutical care into a patient’s overall health care
plan requires effective and efficient communication among health
care professionals
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Documentation…
• Documentation refers to all the patient-specific information, the clinical
decisions, and the patient outcomes that are recorded for use in practice
• In pharmacy practice documentation is
• A written communication that must be mastered by the pharmaceutical
care practitioner and record of the care provided to the patient
• This includes everything
• Written down in hand or
• Entered into a computer program that becomes data and is used to
facilitate the care of the patient
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Documentation….
• Documentation is a major part of pharmaceutical care
• As an integral member of the health care team, the pharmacist must
document the care provided in a permanent manner
• It’s vital to a patient’s continuity of care and demonstrates both
the accountability of the pharmacist and the value of the
pharmacist’s services
• All patient care that is provided as medication management services
must be documented to meet ethical, professional, and legal
guidelines and standards
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Documentation….
• The pharmaceutical care practitioner must contribute in the same manner as
other patient care providers do, likewise nurses, physician or others
• Each step in the patient care process should be documented
• This information can put
• patient's medical chart or
• separate pharmaceutical care patient chart
• Documentation of patient care is not optional in the current health care
system
• Documentation is mandatory to operate any patient care practice
• Patient care cannot be provided, ethically, without a written record
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Documentation….
• Documentation service even expand to community pharmacies
• Community pharmacists are document their daily interventions
to improving drug therapy for their patients
• Developed countries assist the community pharmacist in
documenting
these
medication-related
problems,
patient
counseling
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Documentation….
• Documentation is a database describing
• The patient and disease information
• Drug
• Decisions related to drug choice
• Dose determinations
• Modalities of administration
• Parameters for patient monitoring
• Patient outcomes in terms of efficacy, length of treatment,
incidence of side effects, toxicity, and other drug-related
behaviors
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Documentation…
 Information a pharmacist may need to document include, but are not
limited to, the following:
• Patient Information (name, card no, age, gender, wt, dx, date of
admission)
• A summary of the patient’s medication history on admission
• Including medication allergies and their manifestations
• Immunization status, social drug use, medication adherence
• Current medication
• Drug name, dosage form, dose, and frequency
• The date at which the patient started and stopped each
medication
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Documentation….
• Oral and written consultations provided to other health care
professionals regarding the patient’s drug therapy selection and
management
• Patient progress should also document (improved, resolved, stable,
partially improved, worsen, failure, expire)
• Pharmacist’s Assessment (Drug Therapy Problem Identification) and
Care Plan
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Documentation…
• Actual and potential drug-related problems that warrant surveillance
• Drug therapy-monitoring findings, including
• The therapeutic appropriateness of the patient’s drug regimen
• Therapeutic duplication in the patient’s drug regimen
• The degree of patient compliance with the prescribed drug
regimen
• Drug–drug, drug–food, drug–laboratory test, and drug–disease
interactions
• Clinical and pharmacokinetic laboratory data pertinent to the
drug regimen
• Actual and potential drug toxicity and adverse effects
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Documentation…
• All significant clinical recommendations and actions should be
documented in the appropriate section of the patient medical records
• Include initiating new medicine therapy, discontinuing medicine
therapy, or changing the product and/or dosage regimen
• Adjustments made to drug dosage, dosage frequency, dosage form,
or route of administration
• Drug-related patient education and counseling provided
• Discharge Medication and Counseling (for inpatients), Record
• Date and time of discharge
• Name, dosage form, and dosage of all discharge medications
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• Counseling and education provided to the patient or caregiver
• It should be documented
• In a permanent manner that makes the information available to
all the health care professionals caring for the patient
• Unofficial, temporary, or removable notes do not provide a
standard of acceptable communication or documentation and
are discouraged
• Write all entries in English
• Date should be uniform with the patient’s chart and use the
Ethiopian calendar with the date/month/year format
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• Pharmacist assessment and care plan
• Recommendation/intervention
-
Name and signature
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• Pharmaceutical Care Progress Note Recording Sheet
Patient name………………Card No……..
• Discharge medication and counseling
Name and signature
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Documentation
• Documentation by pharmacists should be
• Legible
• Clear
• Complete
• Ensure that patient privacy and confidentiality are safeguarded
and the communication is concise and accurate
• Appropriate use of a standard format (requires Name and
Signature )
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Documentation…
Be Timely
• Document a patient's care as soon as possible after providing the
care
• This is only logical in that critical information can be forgotten or
confused with the passing of time
• Also other people may need to use the information for the patient's
benefit, making it necessary to have the information available as
soon as possible
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Documentation…
Be Precise
• it is important that report an exact values and clear descriptions with
accurate evidence
• Do not guess, do not estimate, and do not be inconclusive about the
judgments
• B/c other practitioners may have to make decisions based on
what you record
• Avoid nonjudgmental words that imply blame (e.g., error, mistake)
or substandard care (e.g., bad, defective, inadequate, inappropriate,
incorrect, insufficient, poor, problem, and unsatisfactory)
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Documentation…
Be Concise
• It is important to be short, to the point, and not waste words
• Avoid unauthorized abbreviations
Be Complete
• Costly mistakes are caused by missing information in documentation
recording patient information
• Other pharmaceutical care practitioners will all require access to the
written patient record
• Therefore, it must be complete, consistent with other patient care
providers, easily retrievable, and up to date
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Reasons to documentation in Practice
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Reason to documentation..
Meeting the Documentation Standard for Patient Care
• Patient care practitioners are expected to record the (professional standard)
• make decisions about a patient's care
• Decisions that were made and
• Results of those decisions
• All patient care providers have an ethical obligation to be accountable for
the decisions they make and the actions they take as well as the results they
produce
• This is impossible without appropriate documentation
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Reason to documentation..
Being Effective and Efficient at Patient Care
• An important reason for creating the pharmaceutical care patient
chart is to provide high quality care to the patient
• Documentation is essential because the patient's conditions,
needs, and outcomes are constantly changing
• No one can remember all the clinically relevant information about
an individual without recording
• Patient care documentation must be constantly updated and
evaluated to improve patient care
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Reason to documentation..
Legal Purposes
• Information in the documentation (patient medical record’s) may
also be used in legal proceedings (e.g., as evidence)
• An obvious reason for documentation is legal liability
• All activities performed for another individual must be documented
• If, in the future, legal action is brought against the practitioner,
appropriate documentation must be available
• Comprehensive documentation certainly provides the practitioner
with an advantage and can minimize liability
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Reason to documentation..
Communication Purposes
• It serves as a tool for communication among health care
professionals
• Providing pharmaceutical care is a collaborative effort between the
practitioner and the patient as well as the patient's other health care
providers
• This requires a record of the patient's care to communicate with
other health care professionals about the patient’s case
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Reason to documentation..
Reimbursement Purposes
• Documentation is a physical evidence that care was provided, and
this is necessary if you are requesting reimbursement for your
services
• Payers work on the assumption that if the service was not
documented, then it was not done
• Payers usually require specific service be provided to them for the
purpose of being reimbursed for a service and for auditing the
quality of the service
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Reason to documentation..
Patient Case Presentations and Reflection in Practice
• Practitioners communicate with each other through the recorded
patient chart
• Education (e.g., for training students)
• They also communicate frequently through the presentation of patient
cases for the purpose of getting advice, asking questions, sharing
responsibilities, or teaching the student
• The chart must be accessible, well organized, and consistently kept
up to date so that information can be extracted and presented in a
timely manner
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Reason to document…
 Research (e.g., for evaluating clinical drug use)
 Documentation used to sorting data, evaluate the practice, or
make changes
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Reason to documentation..
• Governmental guidelines will require documentation systems used
by pharmaceutical care practitioners to
 (a) meet meaningful use criteria
 (b) communicate with other patient care systems, and
 (c) generate research data to improve patient care and
population health in the future
 Research (e.g., for evaluating clinical drug use)
 Quality assurance evaluations (e.g., to ascertain adherence
to practice standards)
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Documentation…
• Document can be done
• Electronically called the “Electronic Therapeutic Record.”
OR
• Paper form of documentation
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Documentation…
 Advantages of the Paper Chart
• It suitable for student learning to practice pharmaceutical care
• The majority of patient charts in institutions are still paper
version
• However
• Handwriting sometimes difficult to interpret
• Key elements may be omitted
• Very time consuming for sorting data to conduct research
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Documentation…
 Electronic
• The patient record can be accessed by multiple practitioners in
multiple sites
• The information can usually be entered from multiple locations
• Easy and quick access
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If you didn't document, you did nothing!!
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